Provider Demographics
NPI:1528452778
Name:DESTAJO, JOSE (RN)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:DESTAJO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9938 SWINTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-1328
Mailing Address - Country:US
Mailing Address - Phone:818-634-1077
Mailing Address - Fax:
Practice Address - Street 1:14238 SARANAC LN
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1435
Practice Address - Country:US
Practice Address - Phone:818-485-0888
Practice Address - Fax:818-833-5690
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA745368163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse