Healthcare Provider Details

I. General information

NPI: 1962950832
Provider Name (Legal Business Name): JEANNETTE MOYA VILLANUEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 25TH ST
SAN DIEGO CA
92102-2102
US

IV. Provider business mailing address

2420 D AVE APT 15
NATIONAL CITY CA
91950-7061
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-6454
  • Fax:
Mailing address:
  • Phone: 619-540-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number95757
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number95757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: