Provider Demographics
NPI:1932688033
Name:CANTU, JONATHAN ALEXANDER
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ALEXANDER
Last Name:CANTU
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 1:655 ENTERPRISE DR APT 196
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2492
Mailing Address - Country:US
Mailing Address - Phone:192-586-4395
Mailing Address - Fax:
Practice Address - Street 1:1466 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2021
Practice Address - Country:US
Practice Address - Phone:415-457-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)