Provider Demographics
NPI:1558130393
Name:ENGELMANN, JONAH
Entity Type:Individual
Prefix:
First Name:JONAH
Middle Name:
Last Name:ENGELMANN
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 1:4927 LAKE RIDGE PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3066
Mailing Address - Country:US
Mailing Address - Phone:214-251-8758
Mailing Address - Fax:
Practice Address - Street 1:4927 LAKE RIDGE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3066
Practice Address - Country:US
Practice Address - Phone:214-251-8758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-23-283336106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician