Healthcare Provider Details

I. General information

NPI: 1154678142
Provider Name (Legal Business Name): JONATHAN WEAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 JULIAN AVE
SAN FRANCISCO CA
94103-3507
US

IV. Provider business mailing address

56 JULIAN AVE
SAN FRANCISCO CA
94103-3507
US

V. Phone/Fax

Practice location:
  • Phone: 415-865-0964
  • Fax:
Mailing address:
  • Phone: 415-865-0964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCICA02071019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: