Healthcare Provider Details

I. General information

NPI: 1841440419
Provider Name (Legal Business Name): JASON R. KORNBERG, M.D., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3252 HOLIDAY CT STE 205
LA JOLLA CA
92037-1808
US

IV. Provider business mailing address

PO BOX 12008
LA JOLLA CA
92039-2008
US

V. Phone/Fax

Practice location:
  • Phone: 858-677-9222
  • Fax:
Mailing address:
  • Phone: 858-677-9222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberA79691
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberA79691
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA79691
License Number StateCA

VIII. Authorized Official

Name: DR. JASON KORNBERG
Title or Position: C.E.O.
Credential: M.D.
Phone: 858-677-9222