Provider Demographics
NPI:1962087114
Name:BETHEL, JONATHAN RYAN (LCSW # 107684)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RYAN
Last Name:BETHEL
Suffix:
Gender:M
Credentials:LCSW # 107684
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1995
Mailing Address - Country:US
Mailing Address - Phone:949-642-2734
Mailing Address - Fax:
Practice Address - Street 1:301 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-7131
Practice Address - Country:US
Practice Address - Phone:949-642-2734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1076841041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical