Provider Demographics
NPI:1073932869
Name:NGUYEN, JESSICA ELENA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELENA
Last Name:NGUYEN
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 1:1722 S LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8520
Mailing Address - Country:US
Mailing Address - Phone:805-366-4254
Mailing Address - Fax:
Practice Address - Street 1:5740 RALSTON ST STE 201
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6571
Practice Address - Country:US
Practice Address - Phone:805-955-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT107691106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist