Provider Demographics
NPI:1720162944
Name:CANICK, JONATHAN D (PHD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:CANICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 WEBSTER STREET
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-2377
Mailing Address - Country:US
Mailing Address - Phone:415-600-1491
Mailing Address - Fax:415-474-9423
Practice Address - Street 1:2100 WEBSTER ST
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2377
Practice Address - Country:US
Practice Address - Phone:415-600-1491
Practice Address - Fax:415-474-9423
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11376103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR23765Medicare UPIN
CA0PL113760Medicare ID - Type UnspecifiedM/CARE AND STATE #