Provider Demographics
NPI:1740699701
Name:CLANCY, JONATHAN PAUL (LMBT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PAUL
Last Name:CLANCY
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 N LOUISIANA AVE STE G4
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-3658
Mailing Address - Country:US
Mailing Address - Phone:828-333-1239
Mailing Address - Fax:
Practice Address - Street 1:370 N LOUISIANA AVE STE G4
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-3658
Practice Address - Country:US
Practice Address - Phone:828-333-1239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14063225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist