Provider Demographics
NPI:1558564765
Name:PON, JASON (MS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3990 WESTERLY PL
Mailing Address - Street 2:SUITE 160
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2310
Mailing Address - Country:US
Mailing Address - Phone:949-415-6895
Mailing Address - Fax:
Practice Address - Street 1:3990 WESTERLY PL
Practice Address - Street 2:SUITE 160
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2310
Practice Address - Country:US
Practice Address - Phone:949-415-6895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 53241106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist