Provider Demographics
NPI:1710478870
Name:GARCIA, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GARCIA
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 1:16946 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:624 COMMERCE AVE STE E
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3883
Practice Address - Country:US
Practice Address - Phone:661-942-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABC0005570106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABC0005570OtherABA