Healthcare Provider Details

I. General information

NPI: 1962234617
Provider Name (Legal Business Name): JONATHAN ERIC ANTCZAK CADC III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28400 MCCALL BLVD FL 3
MENIFEE CA
92585-9658
US

IV. Provider business mailing address

371 N WESTON PL
HEMET CA
92543-3006
US

V. Phone/Fax

Practice location:
  • Phone: 951-679-8888
  • Fax:
Mailing address:
  • Phone: 951-287-8777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: