Healthcare Provider Details

I. General information

NPI: 1699244509
Provider Name (Legal Business Name): JON JOSEPH CISNEROS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 NW MONROE AVE STE 103
CORVALLIS OR
97330-4708
US

IV. Provider business mailing address

151 NW MONROE AVE STE 103
CORVALLIS OR
97330-4708
US

V. Phone/Fax

Practice location:
  • Phone: 541-517-4542
  • Fax:
Mailing address:
  • Phone: 541-517-4542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-1825
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3354
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: