Healthcare Provider Details

I. General information

NPI: 1043932817
Provider Name (Legal Business Name): JONATHAN BUENROSTRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 JEFFERSON BLVD STE B180
WEST SACRAMENTO CA
95605-2394
US

IV. Provider business mailing address

500 JEFFERSON BLVD STE B180
WEST SACRAMENTO CA
95605-2394
US

V. Phone/Fax

Practice location:
  • Phone: 916-403-2900
  • Fax:
Mailing address:
  • Phone: 916-403-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1594480125
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: