Provider Demographics
NPI:1184014607
Name:MEDINA, JANET
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3569 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2607
Mailing Address - Country:US
Mailing Address - Phone:562-595-1159
Mailing Address - Fax:
Practice Address - Street 1:1301 PINE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813
Practice Address - Country:US
Practice Address - Phone:562-595-1159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF84581101YM0800X
CA106065106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health