Provider Demographics
NPI:1184863607
Name:SANDOVAL, JESICA
Entity Type:Individual
Prefix:
First Name:JESICA
Middle Name:
Last Name:SANDOVAL
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 1:3701 STOCKER ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5144
Mailing Address - Country:US
Mailing Address - Phone:323-294-7296
Mailing Address - Fax:323-294-7297
Practice Address - Street 1:3701 STOCKER ST STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5144
Practice Address - Country:US
Practice Address - Phone:323-294-7296
Practice Address - Fax:323-294-7297
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor