Provider Demographics
NPI:1669000667
Name:TELLES, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:TELLES
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 1:621 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-6613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:87 W MARCH LN STE 6
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5731
Practice Address - Country:US
Practice Address - Phone:209-345-7353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician