Basic Information
| Provider Information | |||||||||
| NPI: | 1245875947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWERS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | SUTHERLAND | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 B ST STE 1570 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921014560 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3853 ROSECRANS ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196150439 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2019 | ||||||||
| LastUpdateDate: | 01/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 95087065 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 163W00000X | 95087065 | CA | N | Nursing Service Providers | Registered Nurse |
No ID Information.