Healthcare Provider Details

I. General information

NPI: 1679237861
Provider Name (Legal Business Name): JOHNMARK VANNESS II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 GEORGETOWN PL
STOCKTON CA
95207-6215
US

IV. Provider business mailing address

3818 SCOTTSDALE RD
LODI CA
95240-6805
US

V. Phone/Fax

Practice location:
  • Phone: 209-955-1139
  • Fax: 209-955-1143
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13809
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: