Provider Demographics
NPI:1669193983
Name:DUARTE MENDOZA, JESUS EDUARDO
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:EDUARDO
Last Name:DUARTE MENDOZA
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 1:2815 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-3322
Mailing Address - Country:US
Mailing Address - Phone:323-621-9676
Mailing Address - Fax:
Practice Address - Street 1:480 ALTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92179-0001
Practice Address - Country:US
Practice Address - Phone:619-661-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health