Provider Demographics
NPI:1902208986
Name:HERNANDEZ, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:HERNANDEZ
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 1:38615 CORTINA WAY
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-8101
Mailing Address - Country:US
Mailing Address - Phone:818-781-0360
Mailing Address - Fax:
Practice Address - Street 1:9650 ZELZAH AVE
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-2003
Practice Address - Country:US
Practice Address - Phone:661-265-8627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-21
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 390200000X
CA1121421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program