Provider Demographics
NPI:1215552443
Name:PAVON, JESSICA CECILIA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CECILIA
Last Name:PAVON
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 1:139 HUGO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2738
Mailing Address - Country:US
Mailing Address - Phone:650-797-2378
Mailing Address - Fax:
Practice Address - Street 1:139 HUGO ST APT 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-2760
Practice Address - Country:US
Practice Address - Phone:650-797-2378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician