Provider Demographics
NPI:1194851410
Name:REYNOSO, JOEY JESSE
Entity Type:Individual
Prefix:
First Name:JOEY
Middle Name:JESSE
Last Name:REYNOSO
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 1:222 W ALAMOS AVE APT 103C
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3611
Mailing Address - Country:US
Mailing Address - Phone:559-790-9785
Mailing Address - Fax:
Practice Address - Street 1:114 E SHAW AVE STE 210
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7621
Practice Address - Country:US
Practice Address - Phone:559-221-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101076OtherDRUG MEDI-CAL