Provider Demographics
NPI:1619124393
Name:SANDBERG, JONATHAN GILBERT (PHD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GILBERT
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 TLRB BRIGHAM YOUNG UNIVERSITY
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602-6710
Mailing Address - Country:US
Mailing Address - Phone:801-422-6512
Mailing Address - Fax:
Practice Address - Street 1:266 TLRB
Practice Address - Street 2:BRIGHAM YOUNG UNIVERSITY
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602
Practice Address - Country:US
Practice Address - Phone:315-422-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7007953-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist