Healthcare Provider Details

I. General information

NPI: 1790804805
Provider Name (Legal Business Name): JOSE BENJAMIN TIJERINA M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 14TH ST
MODESTO CA
95354-2506
US

IV. Provider business mailing address

707 14TH ST
MODESTO CA
95354-2506
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-5084
  • Fax:
Mailing address:
  • Phone: 209-525-5084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: