Provider Demographics
NPI:1780145581
Name:LAW, JONATHAN (LAC)
Entity type:Individual
Prefix:PROF
First Name:JONATHAN
Middle Name:
Last Name:LAW
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 MESA VERDE DR E STE 111
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5221
Mailing Address - Country:US
Mailing Address - Phone:949-642-8883
Mailing Address - Fax:949-207-6333
Practice Address - Street 1:1525 MESA VERDE DR E STE 111
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5221
Practice Address - Country:US
Practice Address - Phone:949-642-8883
Practice Address - Fax:949-207-6333
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4726171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist