Provider Demographics
NPI:1073360723
Name:HERNANDEZ, JOSE MANUEL II
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:MANUEL
Last Name:HERNANDEZ
Suffix:II
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 1:4706 CALDWELL RD E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98372-9221
Mailing Address - Country:US
Mailing Address - Phone:360-927-6758
Mailing Address - Fax:
Practice Address - Street 1:950 BROADWAY STE 301
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4454
Practice Address - Country:US
Practice Address - Phone:253-671-9909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61550345106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician