Basic Information
| Provider Information | |||||||||
| NPI: | 1922519487 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | JAVIER | ||||||||
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| Credential: | MA, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 938 WILLOWLEAF DR APT 2801 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951283697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502919026 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3301 E 12TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946013424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102699030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 124026 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.