Provider Demographics
NPI:1720386337
Name:MIKULAK, JONATHAN DANIEL (LSW)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DANIEL
Last Name:MIKULAK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6134 HALLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:PA
Mailing Address - Zip Code:15147-2523
Mailing Address - Country:US
Mailing Address - Phone:412-996-6818
Mailing Address - Fax:
Practice Address - Street 1:3063 FREEPORT RD
Practice Address - Street 2:SUITE B
Practice Address - City:NATRONA HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:15065-1967
Practice Address - Country:US
Practice Address - Phone:724-766-9238
Practice Address - Fax:724-226-0931
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-06
Last Update Date:2011-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW126542104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker