Basic Information
| Provider Information | |||||||||
| NPI: | 1528452778 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESTAJO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9938 SWINTON AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913431328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186341077 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14238 SARANAC LN | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913421435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184850888 | ||||||||
| FaxNumber: | 8188335690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2015 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 745368 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.