Provider Demographics
NPI:1255107744
Name:CRISOSTOMO, JESUS JAVIER SR
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:JAVIER
Last Name:CRISOSTOMO
Suffix:SR
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 1:27471 BELLOGENTE
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6401
Mailing Address - Country:US
Mailing Address - Phone:949-712-9587
Mailing Address - Fax:
Practice Address - Street 1:27471 BELLOGENTE
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6401
Practice Address - Country:US
Practice Address - Phone:949-712-9587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty