Healthcare Provider Details

I. General information

NPI: 1114762853
Provider Name (Legal Business Name): JONATHAN PATRICK DOUGHERTY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

IV. Provider business mailing address

20335 DAMIETTA DR
WALNUT CA
91789-3723
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: