Provider Demographics
NPI:1730965351
Name:DE LUNA, MC JASON FRIAS (LPC-178)
Entity type:Individual
Prefix:
First Name:MC JASON
Middle Name:FRIAS
Last Name:DE LUNA
Suffix:
Gender:M
Credentials:LPC-178
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9612
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96931-5612
Mailing Address - Country:US
Mailing Address - Phone:671-747-2132
Mailing Address - Fax:
Practice Address - Street 1:790 GOV CARLOS G CAMACHO RD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3129
Practice Address - Country:US
Practice Address - Phone:671-647-2056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GULPC-178101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional