Provider Demographics
NPI:1447337597
Name:MANGOLD, JONATHAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:MANGOLD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:DONALD
Other - Middle Name:
Other - Last Name:JOLLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:255 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-1434
Mailing Address - Country:US
Mailing Address - Phone:317-873-9573
Mailing Address - Fax:
Practice Address - Street 1:260 S 1ST ST
Practice Address - Street 2:S 1
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-1602
Practice Address - Country:US
Practice Address - Phone:317-873-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040052A103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist