Provider Demographics
NPI:1083098859
Name:SISCO-ASENCIO, JEREMIAH DAVID II
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:DAVID
Last Name:SISCO-ASENCIO
Suffix:II
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 1:3433 W SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3229
Mailing Address - Country:US
Mailing Address - Phone:559-558-4051
Mailing Address - Fax:
Practice Address - Street 1:4411 E KINGS CANYON RD # 319
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-2382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-12
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225561101YM0800X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health