Basic Information
| Provider Information | |||||||||
| NPI: | 1851765168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | JOVANA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2772 MARTIN LUTHER KING BLVD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592654800 | ||||||||
| FaxNumber: | 5592654823 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 E KINGS CANYON RD # 319 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596002382 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2015 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 126369 | CA | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 87632 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 126369 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 126369 | 01 | CA | MARRIAGE FAMILY THERAPIST INTERN | OTHER |