Provider Demographics
NPI:1881933158
Name:MIX, JONATHAN JACOB
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JACOB
Last Name:MIX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2298 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2696
Mailing Address - Country:US
Mailing Address - Phone:702-363-7284
Mailing Address - Fax:
Practice Address - Street 1:2298 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2696
Practice Address - Country:US
Practice Address - Phone:702-363-7284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor