Provider Demographics
NPI:1750041000
Name:TROTTER, JONATHAN LEE SR (RADT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:LEE
Last Name:TROTTER
Suffix:SR
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 VENICE BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5060
Mailing Address - Country:US
Mailing Address - Phone:310-801-7206
Mailing Address - Fax:
Practice Address - Street 1:1421 VENICE BLVD APT 2
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-5060
Practice Address - Country:US
Practice Address - Phone:310-801-7206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1398500720106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician