Healthcare Provider Details

I. General information

NPI: 1215196217
Provider Name (Legal Business Name): JESUS JAVIER LUNA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: J. JAVIER LUNA PH.D.

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MAIN ST
WINTERS CA
95694-1722
US

IV. Provider business mailing address

23 MAIN ST
WINTERS CA
95694-1722
US

V. Phone/Fax

Practice location:
  • Phone: 530-795-4377
  • Fax: 530-795-3054
Mailing address:
  • Phone: 530-795-4377
  • Fax: 530-795-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25189
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number25189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: