Provider Demographics
NPI:1457180739
Name:COVARRUBIAS, JESUS DAVID
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:DAVID
Last Name:COVARRUBIAS
Suffix:
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 1:831 W LOCKEFORD ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-1633
Mailing Address - Country:US
Mailing Address - Phone:209-331-7451
Mailing Address - Fax:
Practice Address - Street 1:831 W LOCKEFORD ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-1633
Practice Address - Country:US
Practice Address - Phone:209-331-7451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230292658101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool