Provider Demographics
NPI:1124510243
Name:MENDOZA, JOHNATHAN JULIO
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:JULIO
Last Name:MENDOZA
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 1:39685 OAK CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4538
Mailing Address - Country:US
Mailing Address - Phone:619-616-5213
Mailing Address - Fax:
Practice Address - Street 1:1701 MISSION AVE STE 230
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-7110
Practice Address - Country:US
Practice Address - Phone:760-712-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician