Provider Demographics
NPI:1952868267
Name:CENTENO, JONATHAN A (MA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
Last Name:CENTENO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W ORANGE GROVE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2032
Mailing Address - Country:US
Mailing Address - Phone:909-236-2006
Mailing Address - Fax:
Practice Address - Street 1:790 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1906
Practice Address - Country:US
Practice Address - Phone:909-625-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112628101YM0800X
CALMFT132126106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health