Provider Demographics
NPI:1326684655
Name:HERNANDEZ, JOSE MIGUEL (MA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MIGUEL
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8321 BARDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-3915
Mailing Address - Country:US
Mailing Address - Phone:818-359-9982
Mailing Address - Fax:
Practice Address - Street 1:14545 SHERMAN CIR
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3087
Practice Address - Country:US
Practice Address - Phone:818-909-6868
Practice Address - Fax:818-902-9637
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC6473101YS0200X
CAAMFT110276106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool