Provider Demographics
NPI:1609585355
Name:AVILA, JESSICA KYOMI
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KYOMI
Last Name:AVILA
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 1:14084 RANCHO RD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-4154
Mailing Address - Country:US
Mailing Address - Phone:714-514-3551
Mailing Address - Fax:
Practice Address - Street 1:VA LONG BEACH HCS ATTN: JESSICA AVILA GEC/CLC
Practice Address - Street 2:MAILSTOP:08/118 5901 EAST 7TH STREET
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803
Practice Address - Country:US
Practice Address - Phone:562-706-9228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist