Provider Demographics
NPI:1952688913
Name:MATSUMOTO, JON DAVID
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:DAVID
Last Name:MATSUMOTO
Suffix:
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 1:522 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-2102
Mailing Address - Country:US
Mailing Address - Phone:562-867-7999
Mailing Address - Fax:
Practice Address - Street 1:522 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-2102
Practice Address - Country:US
Practice Address - Phone:562-867-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 288351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical