Provider Demographics
NPI:1558689448
Name:HIATT, JESSIE JANETTE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:JANETTE
Last Name:HIATT
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 1:330 RANCHEROS DR STE 218
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2978
Mailing Address - Country:US
Mailing Address - Phone:760-500-3863
Mailing Address - Fax:
Practice Address - Street 1:330 RANCHEROS DR STE 218
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069
Practice Address - Country:US
Practice Address - Phone:760-500-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97510106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist