Healthcare Provider Details

I. General information

NPI: 1114362167
Provider Name (Legal Business Name): JUAN HERNANDEZ RRW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

976 LENZEN AVE SAN JOSE, ROOM 12
SAN JOSE CA
95126-2737
US

IV. Provider business mailing address

151 W MISSION ST SUITE, 100
SAN JOSE CA
95110-1713
US

V. Phone/Fax

Practice location:
  • Phone: 408-792-5257
  • Fax: 408-947-8719
Mailing address:
  • Phone: 408-535-4004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR2571014
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: