Provider Demographics
NPI:1063914166
Name:HERNANDEZ, JEFFREY (APCC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 GATEWAY CENTER WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4550
Mailing Address - Country:US
Mailing Address - Phone:619-398-2156
Mailing Address - Fax:
Practice Address - Street 1:995 GATEWAY CENTER WAY STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4550
Practice Address - Country:US
Practice Address - Phone:619-398-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2024-03-15
Deactivation Date:2023-09-13
Deactivation Code:
Reactivation Date:2023-10-05
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 101YM0800X, 171M00000X
CAAPCC15883101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator