Provider Demographics
NPI:1043801558
Name:CRAIN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CRAIN
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 1:1639 BUTTERCUP RD
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2450
Mailing Address - Country:US
Mailing Address - Phone:760-846-1351
Mailing Address - Fax:
Practice Address - Street 1:1639 BUTTERCUP RD
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2450
Practice Address - Country:US
Practice Address - Phone:760-846-1351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-20-125805106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician