Provider Demographics
NPI:1477159531
Name:PARK, JESSIKA DENISE (AMFT, APCC)
Entity Type:Individual
Prefix:MS
First Name:JESSIKA
Middle Name:DENISE
Last Name:PARK
Suffix:
Gender:F
Credentials:AMFT, APCC
Other - Prefix:MS
Other - First Name:JESSIKA
Other - Middle Name:DENISE
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1169 S MAIN ST UNIT 160
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-5747
Mailing Address - Country:US
Mailing Address - Phone:209-629-6275
Mailing Address - Fax:
Practice Address - Street 1:1305 TOMMYDON ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3364
Practice Address - Country:US
Practice Address - Phone:209-476-5960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT131422106H00000X, 106H00000X
CAAPCC11203101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health