Healthcare Provider Details

I. General information

NPI: 1720162944
Provider Name (Legal Business Name): JONATHAN D CANICK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 WEBSTER ST SUITE 320
SAN FRANCISCO CA
94115-2377
US

IV. Provider business mailing address

2100 WEBSTER STREET SUITE 320
SAN FRANCISCO CA
94115-2377
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-1491
  • Fax: 415-474-9423
Mailing address:
  • Phone: 415-600-1491
  • Fax: 415-474-9423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY11376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: