Healthcare Provider Details

I. General information

NPI: 1700591351
Provider Name (Legal Business Name): JONATHAN KORBELAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 GRISWOLD AVE
SAN FERNANDO CA
91340-2105
US

IV. Provider business mailing address

10458 PETIT AVE
GRANADA HILLS CA
91344-7313
US

V. Phone/Fax

Practice location:
  • Phone: 747-500-9405
  • Fax:
Mailing address:
  • Phone: 626-679-4080
  • 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: