Provider Demographics
NPI:1720755929
Name:KING, JONATHAN DAVID (MS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:KING
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:JD
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:61 AUSTIN
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-2549
Mailing Address - Country:US
Mailing Address - Phone:951-347-6542
Mailing Address - Fax:
Practice Address - Street 1:13200 CROSSROADS PKWY N STE 335
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3485
Practice Address - Country:US
Practice Address - Phone:562-821-9603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA274964106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist