Healthcare Provider Details

I. General information

NPI: 1386015899
Provider Name (Legal Business Name): JOSE VENEGAS MORENO MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E VIRGINIA ST
SAN JOSE CA
95112-5857
US

IV. Provider business mailing address

160 E VIRGINIA ST
SAN JOSE CA
95112-5857
US

V. Phone/Fax

Practice location:
  • Phone: 408-579-6178
  • Fax:
Mailing address:
  • Phone: 408-579-6178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number89520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: