Provider Demographics
NPI:1174347405
Name:AYALA, JON MANUEL
Entity type:Individual
Prefix:
First Name:JON
Middle Name:MANUEL
Last Name:AYALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6624 FLORA AVE APT F
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-2441
Mailing Address - Country:US
Mailing Address - Phone:323-440-0022
Mailing Address - Fax:
Practice Address - Street 1:5427 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4101
Practice Address - Country:US
Practice Address - Phone:888-499-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104326101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health