1841637923 NPI number — MR. JONATHAN BLAKE VARDELL L.P.C

Table of content: MR. JONATHAN BLAKE VARDELL L.P.C (NPI 1841637923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841637923 NPI number — MR. JONATHAN BLAKE VARDELL L.P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VARDELL
Provider First Name:
JONATHAN
Provider Middle Name:
BLAKE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
L.P.C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VARDELL
Provider Other First Name:
BLAKE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1841637923
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 844658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-3855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROUND ROCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78665-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-724-2111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  74175 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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