Provider Demographics
NPI:1376996694
Name:COMSTOCK, JESSIE LYNN
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LYNN
Last Name:COMSTOCK
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 1:617 S OLIVE ST
Mailing Address - Street 2:SUITE 708
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-1605
Mailing Address - Country:US
Mailing Address - Phone:213-915-6380
Mailing Address - Fax:
Practice Address - Street 1:617 S OLIVE ST
Practice Address - Street 2:SUITE 708
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-1605
Practice Address - Country:US
Practice Address - Phone:213-915-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80671106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist