Provider Demographics
NPI:1275313124
Name:AMBROSE, JONATHAN ROBERT (LPC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 19TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2253
Mailing Address - Country:US
Mailing Address - Phone:717-380-2059
Mailing Address - Fax:
Practice Address - Street 1:137 MONTGOMERY AVE STE 105
Practice Address - Street 2:
Practice Address - City:BOYERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19512-1300
Practice Address - Country:US
Practice Address - Phone:800-689-0250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015318101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional