Provider Demographics
NPI:1366011371
Name:CARBONARO, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CARBONARO
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 1:2701 N 16TH ST STE 316
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1266
Mailing Address - Country:US
Mailing Address - Phone:602-650-1212
Mailing Address - Fax:
Practice Address - Street 1:9890 COUNTY FARM RD STE 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3678
Practice Address - Country:US
Practice Address - Phone:602-650-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121586101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health