Healthcare Provider Details

I. General information

NPI: 1952868267
Provider Name (Legal Business Name): JONATHAN A CENTENO MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 E BONITA AVE
POMONA CA
91767-1906
US

IV. Provider business mailing address

1800 W ORANGE GROVE AVE APT 1
POMONA CA
91768-2032
US

V. Phone/Fax

Practice location:
  • Phone: 909-625-7207
  • Fax:
Mailing address:
  • Phone: 909-236-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number112628
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT132126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: