=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932688033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN ALEXANDER CANTU
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2018
-----------------------------------------------------
Last Update Date | 08/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1466 LINCOLN AVE
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-457-3755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 655 ENTERPRISE DR APT 196
-----------------------------------------------------
City | ROHNERT PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94928-2492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 192-586-4395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------