Provider Demographics
NPI:1902416787
Name:MALDONADO, JESENYA GUADALUPE
Entity Type:Individual
Prefix:
First Name:JESENYA
Middle Name:GUADALUPE
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5628 E. SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:CITY OF COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040
Mailing Address - Country:US
Mailing Address - Phone:323-318-3423
Mailing Address - Fax:323-780-3211
Practice Address - Street 1:5628 E. SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:CITY OF COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040
Practice Address - Country:US
Practice Address - Phone:323-318-9960
Practice Address - Fax:323-780-3211
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2024-01-19
Deactivation Date:2024-01-10
Deactivation Code:
Reactivation Date:2024-01-17
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 390200000X
CA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL
CA95-2633765OtherMEDICAL