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General NPI Number Information
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NPI Number | 1629770904
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Entity Type | Individual
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Provider Name | JATHANIEL A PETTITT LPCC
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Gender | Male
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Dates
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Enumeration Date | 03/20/2023
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Last Update Date | 03/20/2023
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Provider Practice Location Address
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Address Line | 12900 PARK PLAZA DR
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City | CERRITOS
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State | CA
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Zip | 90703-9329
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Country | US
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Telephone | 305-630-1346
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Fax |
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Provider Business Mailing Address
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Address Line | 17378 W PIMA ST
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City | GOODYEAR
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State | AZ
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Zip | 85338-1962
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Country | US
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Telephone | 972-841-9262
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC-19640
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 66158
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC-19640
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 66158
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License Number State | TX
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Taxonomy #5
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPCC10824
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPCC10824
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License Number State | CA
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