Provider Demographics
NPI:1124655642
Name:FUENTES, JUANITA RENEE (RADT1R1318020818)
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:RENEE
Last Name:FUENTES
Suffix:
Gender:F
Credentials:RADT1R1318020818
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-2132
Mailing Address - Country:US
Mailing Address - Phone:408-998-5191
Mailing Address - Fax:
Practice Address - Street 1:102 S 11TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-2132
Practice Address - Country:US
Practice Address - Phone:408-998-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)