Basic Information
| Provider Information | |||||||||
| NPI: | 1447570197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STATT | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 89784 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857529784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204477440 | ||||||||
| FaxNumber: | 5203064861 | ||||||||
| Practice Location | |||||||||
| Address1: | 1022 W INA RD # 103 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857043109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204477440 | ||||||||
| FaxNumber: | 5203064861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2010 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT-10409 | AZ | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 869846 | 05 | AZ | MEDICAID |