Provider Demographics
NPI:1417261405
Name:FOGEL, JONATHAN MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:FOGEL
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 1:2614 N VICKIE ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-8715
Mailing Address - Country:US
Mailing Address - Phone:559-429-5211
Mailing Address - Fax:
Practice Address - Street 1:2614 N VICKIE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-8715
Practice Address - Country:US
Practice Address - Phone:559-429-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23570103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical