MEDICARE: DR. JONATHON M WUTKE PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PS2452	ME

General Provider Information

NPI Number	:	1437889425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHON M WUTKE PSYD

Provider Business Mailing Address
First Line	:	1420 TURK ST APT 901
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-4789
Country	:	US
Telephone Number	:	262-206-8127
Fax Number	:

Provider Business Practice Location Address
First Line	:	833 MARKET ST STE 809
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94103-1828
Country	:	US
Telephone Number	:	415-627-9095
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2022
Last Update Date	:	06/13/2022

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