Provider Demographics
NPI:1730436924
Name:MONDRAGON, JONATHAN EDWARD (LPN)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
Last Name:MONDRAGON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16141 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-3519
Mailing Address - Country:US
Mailing Address - Phone:503-252-3949
Mailing Address - Fax:503-252-4027
Practice Address - Street 1:16141 E. BURNSIDE ST.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-3519
Practice Address - Country:US
Practice Address - Phone:503-252-3949
Practice Address - Fax:503-252-4027
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130027LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse