Provider Demographics
NPI:1235348012
Name:HERNANDEZ, JOSE R (ASW)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8902 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6401
Mailing Address - Country:US
Mailing Address - Phone:818-830-7033
Mailing Address - Fax:
Practice Address - Street 1:8902 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-6401
Practice Address - Country:US
Practice Address - Phone:818-830-7033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW109751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW10975OtherLICENSE
CAFHC70468FMedicaid