Provider Demographics
NPI:1346082831
Name:SIBONGA, JAN CHRISTIAN
Entity type:Individual
Prefix:
First Name:JAN CHRISTIAN
Middle Name:
Last Name:SIBONGA
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 1:1820 W EL NORTE PKWY APT B4
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-3365
Mailing Address - Country:US
Mailing Address - Phone:818-681-4227
Mailing Address - Fax:
Practice Address - Street 1:5870 EL CAMINO REAL STE 101
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-8816
Practice Address - Country:US
Practice Address - Phone:581-876-0539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician