Provider Demographics
NPI:1104451392
Name:VELASQUEZ, JOSE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:VELASQUEZ
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 1:200 E CAMPUS VIEW BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-4678
Mailing Address - Country:US
Mailing Address - Phone:614-368-6311
Mailing Address - Fax:
Practice Address - Street 1:200 E CAMPUS VIEW BLVD STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4678
Practice Address - Country:US
Practice Address - Phone:614-368-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-08
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA172950101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)