Provider Demographics
NPI:1811410020
Name:PADILLA JARDON, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:PADILLA JARDON
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 1:625 FAIR OAKS AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5805
Mailing Address - Country:US
Mailing Address - Phone:626-441-4221
Mailing Address - Fax:
Practice Address - Street 1:625 FAIR OAKS AVE STE 300
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-5805
Practice Address - Country:US
Practice Address - Phone:626-441-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 390200000X, 104100000X
CA102790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health