Healthcare Provider Details

I. General information

NPI: 1023870847
Provider Name (Legal Business Name): JONATHAN GEIDEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E 13TH ST
HOLLAND MI
49423-3622
US

IV. Provider business mailing address

201 E CENTER ST STE 112-3334
ANAHEIM CA
92805-7204
US

V. Phone/Fax

Practice location:
  • Phone: 414-797-3334
  • Fax:
Mailing address:
  • Phone: 414-797-3334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT163728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: