Provider Demographics
NPI:1275261935
Name:OLDENBURG, MARK JONATHAN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JONATHAN
Last Name:OLDENBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 FOX CREEK DR APT 5
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-1314
Mailing Address - Country:US
Mailing Address - Phone:262-366-7948
Mailing Address - Fax:
Practice Address - Street 1:13035 W BLUEMOUND RD STE 100
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-8001
Practice Address - Country:US
Practice Address - Phone:262-784-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional