Provider Demographics
NPI:1134541105
Name:ANTHONY, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ANTHONY
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 1:3708 OCEAN RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-2703
Mailing Address - Country:US
Mailing Address - Phone:442-266-6484
Mailing Address - Fax:
Practice Address - Street 1:3142 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-3619
Practice Address - Country:US
Practice Address - Phone:760-842-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA354621041C0700X
CA1013491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical