MEDICARE: MR. JONATHAN MALICDEM

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
1	101YM0800X	Mental Health Counselor
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1619276276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN MALICDEM

Provider Business Mailing Address
First Line	:	4612 ROOSEVELT AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95820-4520
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4612 ROOSEVELT AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95820-4520
Country	:	US
Telephone Number	:	916-457-3129
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	09/02/2020

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