Provider Demographics
NPI:1184783722
Name:MARMORSTEIN, JONATHAN (MA, LPA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MARMORSTEIN
Suffix:
Gender:M
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6008
Mailing Address - Country:US
Mailing Address - Phone:910-347-3010
Mailing Address - Fax:910-347-3201
Practice Address - Street 1:1703 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6006
Practice Address - Country:US
Practice Address - Phone:910-347-3010
Practice Address - Fax:910-347-3201
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3318103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC068AFOtherBC/BS
NC6107479Medicaid