Provider Demographics
NPI:1164799003
Name:HERNANDEZ, JOSE R
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31772 CASINO DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4502
Mailing Address - Country:US
Mailing Address - Phone:951-457-3175
Mailing Address - Fax:
Practice Address - Street 1:31772 CASINO DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4502
Practice Address - Country:US
Practice Address - Phone:951-457-3175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115114104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker