Healthcare Provider Details

I. General information

NPI: 1225845316
Provider Name (Legal Business Name): JOSE M HERNANDEZ LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1852 N MASTICK WAY
NOGALES AZ
85621-1063
US

IV. Provider business mailing address

825 N GRAND AVE STE 100
NOGALES AZ
85621-1061
US

V. Phone/Fax

Practice location:
  • Phone: 520-281-1550
  • Fax: 520-281-4487
Mailing address:
  • Phone: 520-761-2128
  • Fax: 520-281-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-25124
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: