Provider Demographics
NPI:1982445813
Name:MEDINA-SANCHEZ, JESUS EDUARDO
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:EDUARDO
Last Name:MEDINA-SANCHEZ
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 1:509 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:RODEO
Mailing Address - State:CA
Mailing Address - Zip Code:94572-1432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 PARKER AVE
Practice Address - Street 2:
Practice Address - City:RODEO
Practice Address - State:CA
Practice Address - Zip Code:94572-1432
Practice Address - Country:US
Practice Address - Phone:510-510-2385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-22-229501106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician