Provider Demographics
NPI:1366834624
Name:CHICOINE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CHICOINE
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:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:COBB
Mailing Address - State:CA
Mailing Address - Zip Code:95426-0042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9430 LAKE ST
Practice Address - Street 2:
Practice Address - City:LOWER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95457-8600
Practice Address - Country:US
Practice Address - Phone:707-994-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health