Provider Demographics
NPI:1548338940
Name:VENN, JONATHAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:VENN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8555 STATION VILLAGE LN
Mailing Address - Street 2:#3139
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-6543
Mailing Address - Country:US
Mailing Address - Phone:619-692-3736
Mailing Address - Fax:
Practice Address - Street 1:8555 STATION VILLAGE LN
Practice Address - Street 2:#3139
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-6543
Practice Address - Country:US
Practice Address - Phone:619-692-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22538103TC0700X, 103TF0200X, 103G00000X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0063Medicaid
SCPS0063Medicaid