Healthcare Provider Details

I. General information

NPI: 1598889529
Provider Name (Legal Business Name): JESUS FAVELA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 9TH ST
MODESTO CA
95354-0713
US

IV. Provider business mailing address

800 SCENIC DR
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4464
  • Fax:
Mailing address:
  • Phone: 209-558-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: