Provider Demographics
NPI:1811005432
Name:VANFOSSAN, JON ALAN
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:ALAN
Last Name:VANFOSSAN
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 1:18389 UTILITY AVE
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-8423
Mailing Address - Country:US
Mailing Address - Phone:530-241-0337
Mailing Address - Fax:
Practice Address - Street 1:2640 BRESLAUER WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-4246
Practice Address - Country:US
Practice Address - Phone:530-245-6416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43861106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOtherMFT