Provider Demographics
NPI:1184300220
Name:KIM, JONATHAN (CADC-II)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17424 BURBANK BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1716
Mailing Address - Country:US
Mailing Address - Phone:310-756-7764
Mailing Address - Fax:
Practice Address - Street 1:80 E HILLCREST DR STE 110
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4226
Practice Address - Country:US
Practice Address - Phone:310-756-7764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAAII063190821101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker