Provider Demographics
NPI:1801529730
Name:BAKER, JOHN WILSON III
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILSON
Last Name:BAKER
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7652
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95604-7652
Mailing Address - Country:US
Mailing Address - Phone:530-492-0114
Mailing Address - Fax:
Practice Address - Street 1:300 HARDING BLVD STE 108
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2471
Practice Address - Country:US
Practice Address - Phone:530-499-8744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT140740106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist