Provider Demographics
NPI:1154382380
Name:ROSE, JONATHON M (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:M
Last Name:ROSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-1918
Mailing Address - Country:US
Mailing Address - Phone:650-703-4769
Mailing Address - Fax:
Practice Address - Street 1:327 N SAN MATEO DR
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2543
Practice Address - Country:US
Practice Address - Phone:650-703-4769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12143103G00000X, 103TA0700X, 103TC0700X, 103TF0200X, 103TH0100X, 103T00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY121430Medicaid
CAPSY121430Medicaid
CA0PL121431Medicare ID - Type Unspecified