Healthcare Provider Details

I. General information

NPI: 1538876982
Provider Name (Legal Business Name): JOSE WILLIAM OQUENDO JR. MSW, M.DIV.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 BUSINESS CENTER DR STE 106
SAN BERNARDINO CA
92408-3447
US

IV. Provider business mailing address

25852 IRIS AVE UNIT A
MORENO VALLEY CA
92551-2943
US

V. Phone/Fax

Practice location:
  • Phone: 909-804-8877
  • Fax:
Mailing address:
  • Phone: 626-319-8127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: