Provider Demographics
NPI:1619437639
Name:ITTARONGK, JONATHAN IRVING
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:IRVING
Last Name:ITTARONGK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22751 SUNROSE ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-8128
Mailing Address - Country:US
Mailing Address - Phone:951-283-8217
Mailing Address - Fax:
Practice Address - Street 1:6301 BEACH BLVD STE 245
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-4031
Practice Address - Country:US
Practice Address - Phone:714-736-0231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT110248106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist