Provider Demographics
NPI:1518418029
Name:LERCH, JONATHAN (3585)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LERCH
Suffix:
Gender:M
Credentials:3585
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 TRAMWAY BLVD NE
Mailing Address - Street 2:APT # 104
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-2145
Mailing Address - Country:US
Mailing Address - Phone:412-552-8109
Mailing Address - Fax:
Practice Address - Street 1:800 CORONADO RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-865-9313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3585224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3585Medicaid