Healthcare Provider Details

I. General information

NPI: 1902620420
Provider Name (Legal Business Name): JOHN OLUSANYA LAJUBUTU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN OLUSANYA LAJUBUTU

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 E CESAR CHAVEZ BLVD
FRESNO CA
93702-3604
US

IV. Provider business mailing address

4441 E CESAR CHAVEZ BLVD
FRESNO CA
93702-3604
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-9180
  • Fax:
Mailing address:
  • Phone: 559-600-9180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number32919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: