Provider Demographics
NPI:1073114401
Name:CHEA, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CHEA
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 1:3832 KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4038
Mailing Address - Country:US
Mailing Address - Phone:626-297-8989
Mailing Address - Fax:
Practice Address - Street 1:17732 BEACH BLVD STE G
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6881
Practice Address - Country:US
Practice Address - Phone:714-655-7142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90642133DMedicaid