Provider Demographics
NPI:1033600333
Name:ANDROS, JESSE RAINE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:RAINE
Last Name:ANDROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 ADDISON ST # 302
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1692
Mailing Address - Country:US
Mailing Address - Phone:415-989-5000
Mailing Address - Fax:
Practice Address - Street 1:2080 ADDISON ST STE 3
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1693
Practice Address - Country:US
Practice Address - Phone:415-989-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst