Provider Demographics
NPI:1679706568
Name:ARDITTI, JONATHAN OMAR (PSYD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:OMAR
Last Name:ARDITTI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11705 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4023
Mailing Address - Country:US
Mailing Address - Phone:949-385-1767
Mailing Address - Fax:
Practice Address - Street 1:550 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:213-222-3797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0200X, 390200000X
CAPSY26815103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program