Provider Demographics
NPI:1487340568
Name:BRAVO, JEAN PIERRE (AMFT 118676)
Entity type:Individual
Prefix:
First Name:JEAN PIERRE
Middle Name:
Last Name:BRAVO
Suffix:
Gender:M
Credentials:AMFT 118676
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2590 REDHILL AVE UNIT 1123
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5521
Mailing Address - Country:US
Mailing Address - Phone:661-932-8590
Mailing Address - Fax:
Practice Address - Street 1:13200 CROSSROADS PKWY N BLDG 300
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3459
Practice Address - Country:US
Practice Address - Phone:562-821-1491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118676106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist