Provider Demographics
NPI:1316124969
Name:FUENTES, JOSE L (PHD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:FUENTES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24230 BARTON RD
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3232
Mailing Address - Country:US
Mailing Address - Phone:190-979-6930
Mailing Address - Fax:909-799-7320
Practice Address - Street 1:24230 BARTON RD
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3232
Practice Address - Country:US
Practice Address - Phone:190-979-6930
Practice Address - Fax:909-799-7320
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist