Provider Demographics
NPI:1376695635
Name:PEDERSEN, JON-PATRIK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JON-PATRIK
Middle Name:
Last Name:PEDERSEN
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 1:102 N MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1710
Mailing Address - Country:US
Mailing Address - Phone:626-449-4737
Mailing Address - Fax:
Practice Address - Street 1:102 N MADISON AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1710
Practice Address - Country:US
Practice Address - Phone:626-449-4737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11837103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical