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NPI Code Detail

MEDICARE: JONATHAN PATRICK DOUGHERTY PSYD

MEDICARE: JONATHAN PATRICK DOUGHERTY PSYD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist35378CA
2103TH0004XHealth Psychologist
3103T00000XPsychologist

General Provider Information

NPI Number : 1114762853
Entity Type Code : Individual
Provider Name (Legal Business Name) : JONATHAN PATRICK DOUGHERTY PSYD
Provider Business Mailing Address
First Line : 20335 DAMIETTA DR
Second Line :
City : WALNUT
State : CA
Zip : 91789-3723
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 11201 BENTON ST
Second Line :
City : LOMA LINDA
State : CA
Zip : 92357-1000
Country : US
Telephone Number : 909-825-7084
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/25/2024
Last Update Date : 01/28/2026

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