Provider Demographics
NPI:1255829727
Name:JESINOSKI, MARK STANLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STANLEY
Last Name:JESINOSKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-2867
Mailing Address - Country:US
Mailing Address - Phone:435-770-8670
Mailing Address - Fax:
Practice Address - Street 1:3355 MISSION AVE STE 111
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1327
Practice Address - Country:US
Practice Address - Phone:760-810-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26433103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist