Provider Demographics
NPI:1235723446
Name:SANTA-CLARA, JESSICA LEE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:SANTA-CLARA
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 1:2460 BURTON ST SE STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4800
Mailing Address - Country:US
Mailing Address - Phone:616-278-1201
Mailing Address - Fax:
Practice Address - Street 1:2460 BURTON ST SE STE 101
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4800
Practice Address - Country:US
Practice Address - Phone:616-278-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS532403497998106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician