Provider Demographics
NPI:1942775101
Name:VELAZQUEZ, JESUS E JR
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:E
Last Name:VELAZQUEZ
Suffix:JR
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 1:2423 SMOKEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-4009
Mailing Address - Country:US
Mailing Address - Phone:760-802-3435
Mailing Address - Fax:
Practice Address - Street 1:8235 SANTA MONICA BLVD STE 302
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5969
Practice Address - Country:US
Practice Address - Phone:888-684-2779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4050101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty