Provider Demographics
NPI:1427378918
Name:FUENTES, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:FUENTES
Suffix:
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 1:1700 MCHENRY VILLAGE WAY
Mailing Address - Street 2:SUITE 14
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4308
Mailing Address - Country:US
Mailing Address - Phone:209-526-1440
Mailing Address - Fax:
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY
Practice Address - Street 2:SUITE 14
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4308
Practice Address - Country:US
Practice Address - Phone:209-526-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator