Provider Demographics
NPI:1346598133
Name:BERNACKI, JESSICA M (PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:BERNACKI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 16TH ST
Practice Address - Street 2:SUITE 125
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1235
Practice Address - Country:US
Practice Address - Phone:310-315-8900
Practice Address - Fax:310-315-8902
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25954103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent