Provider Demographics
NPI:1285114801
Name:VERDUZCO MORENO, JESUS ITZEL
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ITZEL
Last Name:VERDUZCO MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 30TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3417
Mailing Address - Country:US
Mailing Address - Phone:619-565-2650
Mailing Address - Fax:
Practice Address - Street 1:1424 30TH ST STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3417
Practice Address - Country:US
Practice Address - Phone:619-565-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16850101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional