Provider Demographics
NPI:1649745282
Name:VITAL, JESUS EFREN
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:EFREN
Last Name:VITAL
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 1:9140 VAN NUYS BLVD STE 211
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-6764
Mailing Address - Country:US
Mailing Address - Phone:818-895-2206
Mailing Address - Fax:818-895-0824
Practice Address - Street 1:9140 VAN NUYS BLVD STE 211
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-6764
Practice Address - Country:US
Practice Address - Phone:818-895-2206
Practice Address - Fax:818-895-0824
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5565101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)