Basic Information
| Provider Information | |||||||||
| NPI: | 1184154767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | PATAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16782 VON KARMAN AVE STE 11 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926062417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552237123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12968 FREDERICK ST | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925535229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512427738 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2017 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106S00000X | RBT-18-65352 | CA | N | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.