Provider Demographics
NPI:1881926269
Name:RAVARINO, JONATHAN MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:RAVARINO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 S 1900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4155
Mailing Address - Country:US
Mailing Address - Phone:801-918-5275
Mailing Address - Fax:
Practice Address - Street 1:201 S 1460 E RM 426
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-9061
Practice Address - Country:US
Practice Address - Phone:801-918-5275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5179442-2501103T00000X
UT5179442-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical