Provider Demographics
NPI:1356837942
Name:MONTENEGRO, JEREMIAS (MA)
Entity Type:Individual
Prefix:
First Name:JEREMIAS
Middle Name:
Last Name:MONTENEGRO
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 1:505 E COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-4009
Mailing Address - Country:US
Mailing Address - Phone:714-773-0077
Mailing Address - Fax:714-773-0067
Practice Address - Street 1:505 E COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-4009
Practice Address - Country:US
Practice Address - Phone:714-773-0077
Practice Address - Fax:714-773-0067
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-30622103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst