Healthcare Provider Details

I. General information

NPI: 1609532522
Provider Name (Legal Business Name): JONATHAN HENDERSHOT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 N FAIR OAKS AVE
PASADENA CA
91103-1642
US

IV. Provider business mailing address

1680 N FAIR OAKS AVE
PASADENA CA
91103-1642
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-0884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: