Healthcare Provider Details

I. General information

NPI: 1144659459
Provider Name (Legal Business Name): MR. FREDERICK JON CHACON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2523 W 7TH ST
LOS ANGELES CA
90057-3801
US

IV. Provider business mailing address

210 S DE LACEY AVE SUITE 110
PASADENA CA
91105-2048
US

V. Phone/Fax

Practice location:
  • Phone: 626-227-7014
  • Fax: 626-227-7015
Mailing address:
  • Phone: 626-395-7100
  • Fax: 626-685-2126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF77897
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: