Provider Demographics
NPI:1659720308
Name:GARCIA, JESSICA LISSETH
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LISSETH
Last Name:GARCIA
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 1:2502 E. HUNTINGTON DR.
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-2221
Mailing Address - Country:US
Mailing Address - Phone:626-263-9133
Mailing Address - Fax:
Practice Address - Street 1:2502 E. HUNTINGTON DR.
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2221
Practice Address - Country:US
Practice Address - Phone:626-263-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97226101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7667OtherMEDICAL
CA7368OtherMEDICAL
CA7184OtherMEDICAL
CA7708OtherMEDICAL