Provider Demographics
NPI:1447800743
Name:BERNAL, JESSICA DOLORES
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DOLORES
Last Name:BERNAL
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 1:4601 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2729
Mailing Address - Country:US
Mailing Address - Phone:213-223-5922
Mailing Address - Fax:323-891-5344
Practice Address - Street 1:14659 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1652
Practice Address - Country:US
Practice Address - Phone:818-485-0888
Practice Address - Fax:818-833-5690
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA959741041C0700X
390200000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program