Provider Demographics
NPI:1568774339
Name:ESTRADA, JONATHAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 CORNELIA STREET
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-4729
Mailing Address - Country:US
Mailing Address - Phone:347-907-2968
Mailing Address - Fax:718-821-5619
Practice Address - Street 1:1633 CORNELIA ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4729
Practice Address - Country:US
Practice Address - Phone:347-907-2968
Practice Address - Fax:718-821-5619
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004129171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist