Provider Demographics
NPI:1164432969
Name:ANDERSON, JON KENNETH (NP)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:KENNETH
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSYCHIATRIC HEALTH FACILITY (YOUTH)
Mailing Address - Street 2:4411 E. KINGS CANYON RD. #319
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702
Mailing Address - Country:US
Mailing Address - Phone:559-600-2382
Mailing Address - Fax:
Practice Address - Street 1:4411 E KINGS CANYON RD # 319
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-2382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA486848163W00000X
CA9868363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ07384Medicare UPIN
CAZZZ28220ZMedicare PIN