Provider Demographics
NPI:1093137978
Name:DAVENPORT, JONTA LA'RON
Entity Type:Individual
Prefix:
First Name:JONTA
Middle Name:LA'RON
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 GLEN CANYON CIR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-6458
Mailing Address - Country:US
Mailing Address - Phone:510-759-1320
Mailing Address - Fax:
Practice Address - Street 1:3480 BUSKIRK AVE STE 210
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4304
Practice Address - Country:US
Practice Address - Phone:925-933-2627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCI13420820101YA0400X
101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)