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General NPI Number Information
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NPI Number | 1679237861
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Entity Type | Individual
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Provider Name | JOHNMARK VANNESS II
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Gender | Male
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Dates
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Enumeration Date | 10/25/2021
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Last Update Date | 01/08/2024
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Provider Practice Location Address
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Address Line | 4545 GEORGETOWN PL
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City | STOCKTON
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State | CA
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Zip | 95207-6215
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Country | US
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Telephone | 209-955-1139
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Fax | 209-955-1143
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Provider Business Mailing Address
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Address Line | 3818 SCOTTSDALE RD
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City | LODI
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State | CA
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Zip | 95240-6805
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Country | US
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Telephone |
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 13809
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License Number State | CA
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