Provider Demographics
NPI:1346350378
Name:GRAYSON, JONATHAN BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BRUCE
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CORDOVA ST UNIT 304
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2749
Mailing Address - Country:US
Mailing Address - Phone:610-416-0122
Mailing Address - Fax:
Practice Address - Street 1:4 E HOLLY ST STE 219
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-4519
Practice Address - Country:US
Practice Address - Phone:626-639-3994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003671L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0049372000OtherINDEPENDENCE BLUE CROSS
PA461698000OtherMAGELLAN
PAGR139646Medicare ID - Type Unspecified