Provider Demographics
NPI:1184974073
Name:PORTO, JONATHAN GAVIN (LMFT 150139)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GAVIN
Last Name:PORTO
Suffix:
Gender:M
Credentials:LMFT 150139
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 W CHANNEL ISLANDS BLVD # 166
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-2133
Mailing Address - Country:US
Mailing Address - Phone:805-512-6764
Mailing Address - Fax:
Practice Address - Street 1:1400 E JANSS RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-2133
Practice Address - Country:US
Practice Address - Phone:805-497-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150139106H00000X
CA97478106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor