Provider Demographics
NPI:1346028594
Name:HERNANDEZ, JOSE LUIS JR
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:HERNANDEZ
Suffix:JR
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 1:102 W BIANCHI RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-7132
Mailing Address - Country:US
Mailing Address - Phone:209-451-3628
Mailing Address - Fax:209-932-9446
Practice Address - Street 1:102 W BIANCHI RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-7132
Practice Address - Country:US
Practice Address - Phone:209-451-3628
Practice Address - Fax:209-932-9446
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)