Provider Demographics
NPI:1407108160
Name:IRAHETA, JOSE RICARDO JR (MFTI)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:RICARDO
Last Name:IRAHETA
Suffix:JR
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6558 MARY ELLEN AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1327
Mailing Address - Country:US
Mailing Address - Phone:818-421-0417
Mailing Address - Fax:
Practice Address - Street 1:435 EDGEMAR AVE
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-1961
Practice Address - Country:US
Practice Address - Phone:650-355-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist