Provider Demographics
NPI:1720540016
Name:ORTEGO, JONATHAN CHANCE (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CHANCE
Last Name:ORTEGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 LARKSPUR LANDING CIR STE 160
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1766
Mailing Address - Country:US
Mailing Address - Phone:707-258-8757
Mailing Address - Fax:
Practice Address - Street 1:900 LARKSPUR LANDING CIR STE 160
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1766
Practice Address - Country:US
Practice Address - Phone:707-258-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1949892084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry