Healthcare Provider Details

I. General information

NPI: 1942024625
Provider Name (Legal Business Name): JUSTIN WADE HURTADO PALOMO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUSTIN WADE PALOMO

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 S 2ND ST
SAN JOSE CA
95112-5823
US

IV. Provider business mailing address

PO BOX 315
VERNON AZ
85940-0315
US

V. Phone/Fax

Practice location:
  • Phone: 408-580-4914
  • Fax:
Mailing address:
  • Phone: 408-580-4914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: