Provider Demographics
NPI:1255684304
Name:PICHETTE, JESSICA LEE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:PICHETTE
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 1:15400 CHOLAME RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2480
Mailing Address - Country:US
Mailing Address - Phone:760-780-4505
Mailing Address - Fax:
Practice Address - Street 1:15400 CHOLAME RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2480
Practice Address - Country:US
Practice Address - Phone:760-780-4505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72830106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist