Healthcare Provider Details

I. General information

NPI: 1023131869
Provider Name (Legal Business Name): JON MICHAEL FAXON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 HOMESTEAD ROAD KAISER PERMANETE -- BEHAVIORAL HEALTH CENTER
SANTA CLARA CA
95051
US

IV. Provider business mailing address

18951 FERNBROOK CT
SARATOGA CA
95070-3424
US

V. Phone/Fax

Practice location:
  • Phone: 408-569-2604
  • Fax:
Mailing address:
  • Phone: 408-569-2604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCSW CA 24839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: