Provider Demographics
NPI:1336332477
Name:JONSON, REUBEN
Entity type:Individual
Prefix:
First Name:REUBEN
Middle Name:
Last Name:JONSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13715 CORDARY AVE APT 271
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-0012
Mailing Address - Country:US
Mailing Address - Phone:310-844-1627
Mailing Address - Fax:
Practice Address - Street 1:4211 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-5622
Practice Address - Country:US
Practice Address - Phone:323-233-0425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265520183Medicaid
CA1306922554Medicaid
CA1841342318Medicaid