Provider Demographics
NPI:1598789471
Name:POON, JOHN (MFT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:POON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-0354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 CADILLAC DR
Practice Address - Street 2:SUITE 126
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-8349
Practice Address - Country:US
Practice Address - Phone:916-346-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36026106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000008462OtherMEDI-CAL PROVIDER NUMBER