Provider Demographics
NPI:1396387643
Name:MONTELONGO, JESUS ROMAN (NONE)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ROMAN
Last Name:MONTELONGO
Suffix:
Gender:M
Credentials:NONE
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:ROMAN
Other - Last Name:MONTELONGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NONE
Mailing Address - Street 1:10635 SCHIRRA AVE UNIT 301
Mailing Address - Street 2:
Mailing Address - City:MATHER
Mailing Address - State:CA
Mailing Address - Zip Code:95655-4156
Mailing Address - Country:US
Mailing Address - Phone:915-487-7913
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1188
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician