Provider Demographics
NPI:1538507660
Name:COLAS, JESSICA JOAN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOAN
Last Name:COLAS
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 1:2620 INDUSTRY WAY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4024
Mailing Address - Country:US
Mailing Address - Phone:310-557-4070
Mailing Address - Fax:
Practice Address - Street 1:2620 INDUSTRY WAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4024
Practice Address - Country:US
Practice Address - Phone:310-557-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACRFLWPAJSBTMKHDZ172V00000X, 175T00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker