Healthcare Provider Details

I. General information

NPI: 1740602978
Provider Name (Legal Business Name): JOSE LUIS CERVANTES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 MORENA BLVD
SAN DIEGO CA
92110-3815
US

IV. Provider business mailing address

10767 JAMACHA BLVD SPC 38
SPRING VALLEY CA
91978-1851
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8715
  • Fax:
Mailing address:
  • Phone: 619-228-3536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number156853
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: