Healthcare Provider Details

I. General information

NPI: 1407366495
Provider Name (Legal Business Name): JONATHAN EDWARD LUCERO LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 10/15/2024
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23161 MILL CREEK DR STE 230
LAGUNA HILLS CA
92653-7935
US

IV. Provider business mailing address

PO BOX 957
ANAHEIM CA
92815-0957
US

V. Phone/Fax

Practice location:
  • Phone: 949-264-5350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: