MEDICARE: JEANETTE LUNA LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	112308	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	872775076	OTHER	CA	IRS

General Provider Information

NPI Number	:	1962160499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANETTE LUNA LMFT

Provider Business Mailing Address
First Line	:	358 E BONITA AVE STE B
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-3172
Country	:	US
Telephone Number	:	909-413-4814
Fax Number	:

Provider Business Practice Location Address
First Line	:	358 E BONITA AVE STE B
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-3172
Country	:	US
Telephone Number	:	909-413-4814
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2021
Last Update Date	:	12/01/2021

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