Provider Demographics
NPI:1326338039
Name:PAGE, JON R (LMFT)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:PAGE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:ROBERT
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:343 E MAIN ST STE 702
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2977
Mailing Address - Country:US
Mailing Address - Phone:209-800-4573
Mailing Address - Fax:
Practice Address - Street 1:343 E MAIN ST STE 702
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202
Practice Address - Country:US
Practice Address - Phone:209-800-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100514106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA8821853OtherDRIVER'S LICENSE