Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) |
NPI | 1164915856 |
---|---|
Provider Name | Mr. Jesus Bracamontes |
First Address | Santa Ana, CA 92706-1457 |
Second Address | Santa Ana, CA 92706-1457 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2018 |
Last Update Date | 07/06/2018 |