Provider Demographics
NPI:1376896787
Name:LI, JESSICA G
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:G
Last Name:LI
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 1:1745 SHADEHILL PL
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2848
Mailing Address - Country:US
Mailing Address - Phone:909-630-8618
Mailing Address - Fax:
Practice Address - Street 1:160 S OLD SPRINGS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92808-1260
Practice Address - Country:US
Practice Address - Phone:714-282-8852
Practice Address - Fax:714-282-8876
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist