Provider Demographics
NPI:1235869892
Name:JOHN, JASSICA W
Entity Type:Individual
Prefix:
First Name:JASSICA
Middle Name:W
Last Name:JOHN
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 1:1413 KINSER RD
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-7291
Mailing Address - Country:US
Mailing Address - Phone:209-409-0825
Mailing Address - Fax:
Practice Address - Street 1:1413 KINSER RD
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-7291
Practice Address - Country:US
Practice Address - Phone:120-940-9082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator