Provider Demographics
NPI:1659026524
Name:MEDINA, JESSENIA CRYSTAL
Entity Type:Individual
Prefix:
First Name:JESSENIA
Middle Name:CRYSTAL
Last Name:MEDINA
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 1:1111 E HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3100
Mailing Address - Country:US
Mailing Address - Phone:559-575-7182
Mailing Address - Fax:
Practice Address - Street 1:215 CENTER ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-4408
Practice Address - Country:US
Practice Address - Phone:559-575-8172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician