Provider Demographics
NPI:1245805860
Name:CEBALLOS, JORGE
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:CEBALLOS
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 1:1400 PARKMOOR AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3798
Mailing Address - Country:US
Mailing Address - Phone:408-961-9888
Mailing Address - Fax:
Practice Address - Street 1:1400 PARKMOOR AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3798
Practice Address - Country:US
Practice Address - Phone:408-961-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker