Provider Demographics
NPI:1285760942
Name:GORTAREZ, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GORTAREZ
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 1:277 SOUTH ST
Mailing Address - Street 2:SUITE T
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5039
Mailing Address - Country:US
Mailing Address - Phone:805-788-2033
Mailing Address - Fax:805-788-2030
Practice Address - Street 1:277 SOUTH ST
Practice Address - Street 2:SUITE T
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5039
Practice Address - Country:US
Practice Address - Phone:805-788-2033
Practice Address - Fax:805-788-2030
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1904OtherCOUNTY MENTAL HEALTH #