Provider Demographics
NPI:1689895682
Name:PEREZ, JOSE A (MA, IMF 59511)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MA, IMF 59511
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9445 FARNHAM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1308
Mailing Address - Country:US
Mailing Address - Phone:619-993-7698
Mailing Address - Fax:
Practice Address - Street 1:9445 FARNHAM ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1308
Practice Address - Country:US
Practice Address - Phone:619-993-7698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 59511106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist