Provider Demographics
NPI:1194574699
Name:BALLESTEROS, JORGE (PHD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21781 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1835
Mailing Address - Country:US
Mailing Address - Phone:818-270-8354
Mailing Address - Fax:
Practice Address - Street 1:21781 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1835
Practice Address - Country:US
Practice Address - Phone:818-270-8354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34652103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty