Provider Demographics
NPI:1679237861
Name:VANNESS, JOHNMARK II
Entity Type:Individual
Prefix:
First Name:JOHNMARK
Middle Name:
Last Name:VANNESS
Suffix:II
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 1:3818 SCOTTSDALE RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-6805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4545 GEORGETOWN PL
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6215
Practice Address - Country:US
Practice Address - Phone:209-955-1139
Practice Address - Fax:209-955-1143
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CA13809101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200806425Medicaid