Provider Demographics
NPI:1073160214
Name:BUENROSTRO, JEREMIAH C
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:C
Last Name:BUENROSTRO
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 1:18646 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1486
Mailing Address - Country:US
Mailing Address - Phone:818-996-1051
Mailing Address - Fax:
Practice Address - Street 1:393 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91188-1486
Practice Address - Country:US
Practice Address - Phone:877-457-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1205031041C0700X
CA96364101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health