Provider Demographics
NPI:1528474160
Name:AQUINO, JOBETH SAN NICOLAS (MA, MFT-124)
Entity type:Individual
Prefix:MRS
First Name:JOBETH
Middle Name:SAN NICOLAS
Last Name:AQUINO
Suffix:
Gender:F
Credentials:MA, MFT-124
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2116
Mailing Address - Street 2:
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:194 HERNAN CORTEZ AVENUE
Practice Address - Street 2:SUITE 210
Practice Address - City:HAGATNA
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-478-5407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUMFT-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist