Healthcare Provider Details

I. General information

NPI: 1790384170
Provider Name (Legal Business Name): JASON BUENO MA, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2020
Last Update Date: 10/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12651 ARTESIA BLVD APT 216
CERRITOS CA
90703-8664
US

IV. Provider business mailing address

12651 ARTESIA BLVD APT 216
CERRITOS CA
90703-8664
US

V. Phone/Fax

Practice location:
  • Phone: 626-247-1090
  • Fax:
Mailing address:
  • Phone: 626-247-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number120386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: