Provider Demographics
NPI:1508307521
Name:JUAREZ, MARTHA YESENIA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:YESENIA
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 K ST # 109
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 34TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2816
Practice Address - Country:US
Practice Address - Phone:510-949-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6917101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional