Provider Demographics
NPI:1649339631
Name:MADDOX, JONATHAN W (MFT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:MADDOX
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-1701
Mailing Address - Country:US
Mailing Address - Phone:415-255-3949
Mailing Address - Fax:
Practice Address - Street 1:2131 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-1701
Practice Address - Country:US
Practice Address - Phone:415-255-3949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39820106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist