Provider Demographics
NPI:1477884195
Name:HERNANDEZ, JESSICA (COTA)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27261 LAS RAMBLAS STE 220
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6468
Mailing Address - Country:US
Mailing Address - Phone:714-966-8650
Mailing Address - Fax:
Practice Address - Street 1:1661 N RAYMOND AVE SUITE 200
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1120
Practice Address - Country:US
Practice Address - Phone:714-966-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1919224Z00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant