Provider Demographics
NPI:1477862415
Name:HENRY, JESSICA JEAN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JEAN
Last Name:HENRY
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 1:24200 WALNUT ST SPC 48
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-6739
Mailing Address - Country:US
Mailing Address - Phone:310-351-2440
Mailing Address - Fax:
Practice Address - Street 1:5150 PCH
Practice Address - Street 2:SUITE100
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804
Practice Address - Country:US
Practice Address - Phone:562-490-7600
Practice Address - Fax:562-490-7601
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF64249106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist