Provider Demographics
NPI:1477732147
Name:DEAN, JONATHAN CRAIG (BS, CAS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CRAIG
Last Name:DEAN
Suffix:
Gender:M
Credentials:BS, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 W VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5704
Mailing Address - Country:US
Mailing Address - Phone:760-940-1836
Mailing Address - Fax:760-940-1274
Practice Address - Street 1:504 W VISTA WAY
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5704
Practice Address - Country:US
Practice Address - Phone:760-940-1836
Practice Address - Fax:760-940-1274
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR0405X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37ABMedicaid