Basic Information
| Provider Information | |||||||||
| NPI: | 1144659459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHACON | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | JON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 S DE LACEY AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263957100 | ||||||||
| FaxNumber: | 6266852126 | ||||||||
| Practice Location | |||||||||
| Address1: | 2523 W 7TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900573801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262277014 | ||||||||
| FaxNumber: | 6262277015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | IMF77897 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 19122731 | 01 | CA | MEDICAL | OTHER |