Provider Demographics
NPI:1124905484
Name:MAH, JONATHAN RYAN (RADT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RYAN
Last Name:MAH
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 SUNRISE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5703
Practice Address - Country:US
Practice Address - Phone:530-273-9541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1623720725101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)