Provider Demographics
NPI:1700346012
Name:MOSSBERG, JONATHAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MOSSBERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-6534
Mailing Address - Country:US
Mailing Address - Phone:914-204-0238
Mailing Address - Fax:
Practice Address - Street 1:1514 N GREENVILLE AVE STE 310
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-1205
Practice Address - Country:US
Practice Address - Phone:547-131-8214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical