Provider Demographics
NPI:1487198727
Name:TATE, JONATHAN LESLIE (MPA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:LESLIE
Last Name:TATE
Suffix:
Gender:M
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 POLK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218-1029
Mailing Address - Country:US
Mailing Address - Phone:313-300-8718
Mailing Address - Fax:
Practice Address - Street 1:258 POLK AVE
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1029
Practice Address - Country:US
Practice Address - Phone:313-300-8718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician