Provider Demographics
NPI:1528223591
Name:DODDS, JONATHAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:DODDS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 CENTRE ST
Mailing Address - Street 2:APARTMENT 9
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3634
Mailing Address - Country:US
Mailing Address - Phone:619-623-2124
Mailing Address - Fax:
Practice Address - Street 1:1804 CABLE ST
Practice Address - Street 2:SUITE B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-3103
Practice Address - Country:US
Practice Address - Phone:619-243-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11688171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist