Provider Demographics
NPI:1295581437
Name:HERNANDEZ, JORGE LEONEL III
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LEONEL
Last Name:HERNANDEZ
Suffix:III
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 1:19076 STROH AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3827
Mailing Address - Country:US
Mailing Address - Phone:951-400-2044
Mailing Address - Fax:
Practice Address - Street 1:6032 VILLAGE RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-3129
Practice Address - Country:US
Practice Address - Phone:951-400-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4358168106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician