Provider Demographics
NPI:1679781017
Name:MANGOLD, JACK (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MANGOLD
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:WILLIAM
Other - Last Name:MANGOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:7001 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-5111
Mailing Address - Country:US
Mailing Address - Phone:240-604-3744
Mailing Address - Fax:
Practice Address - Street 1:4804 MONTGOMERY LN
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-5302
Practice Address - Country:US
Practice Address - Phone:240-604-3744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD110741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical