Provider Demographics
NPI:1619726528
Name:FUENTES, JONATHAN ANDREW (DC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANDREW
Last Name:FUENTES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-4506
Mailing Address - Country:US
Mailing Address - Phone:818-669-2346
Mailing Address - Fax:
Practice Address - Street 1:1365 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94158-2201
Practice Address - Country:US
Practice Address - Phone:415-788-8700
Practice Address - Fax:415-788-8702
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36848111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor