Healthcare Provider Details

I. General information

NPI: 1528793221
Provider Name (Legal Business Name): JOSE ALEXIS CISNEROS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 03/09/2023
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3321 W KENNEWICK AVE STE 150
KENNEWICK WA
99336-2968
US

IV. Provider business mailing address

3321 W KENNEWICK AVE STE 150
KENNEWICK WA
99336-2968
US

V. Phone/Fax

Practice location:
  • Phone: 509-735-6446
  • Fax:
Mailing address:
  • Phone: 509-735-6446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: