Provider Demographics
NPI:1922519487
Name:MEDINA, JOSE JAVIER (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:JAVIER
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 WILLOWLEAF DR APT 2801
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3697
Mailing Address - Country:US
Mailing Address - Phone:650-291-9026
Mailing Address - Fax:
Practice Address - Street 1:3301 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3424
Practice Address - Country:US
Practice Address - Phone:510-269-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124026106H00000X
CA102728390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist