=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023870847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN GEIDEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2024
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28693 OLD TOWN FRONT ST STE 300-F
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92590-2786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-650-3729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 HENRY CT
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95376-1310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-217-9692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | AMFT143112
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------