Provider Demographics
NPI:1508342387
Name:VAZQUEZ, JESSICA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 S NEW HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-1355
Mailing Address - Country:US
Mailing Address - Phone:213-693-2500
Mailing Address - Fax:
Practice Address - Street 1:679 S NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1355
Practice Address - Country:US
Practice Address - Phone:213-693-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89109101YM0800X
390200000X
CALCSW1075931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty