Provider Demographics
NPI:1639561871
Name:FERNANDEZ, JOHN JUSTIN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JUSTIN
Last Name:FERNANDEZ
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 1:232 E GISH RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-4706
Mailing Address - Country:US
Mailing Address - Phone:408-355-0475
Mailing Address - Fax:408-876-4250
Practice Address - Street 1:232 E GISH RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4706
Practice Address - Country:US
Practice Address - Phone:408-355-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90837106H00000X
174400000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist