Provider Demographics
NPI:1841440419
Name:JASON R. KORNBERG, M.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JASON R. KORNBERG, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-677-9222
Mailing Address - Street 1:PO BOX 12008
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92039-2008
Mailing Address - Country:US
Mailing Address - Phone:858-677-9222
Mailing Address - Fax:
Practice Address - Street 1:2247 SAN DIEGO AVE STE 134
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2943
Practice Address - Country:US
Practice Address - Phone:858-677-9222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA796912084P0015X, 2084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic MedicineGroup - Single Specialty
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Single Specialty