Provider Demographics
NPI:1689054405
Name:CARSON, JESSICA RAE (BSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RAE
Last Name:CARSON
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:RAE
Other - Last Name:VOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4550 MONTAIR AVE
Mailing Address - Street 2:#F20
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1259
Mailing Address - Country:US
Mailing Address - Phone:951-501-9787
Mailing Address - Fax:
Practice Address - Street 1:8939 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 460
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3631
Practice Address - Country:US
Practice Address - Phone:310-337-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-06
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UNLICENSED225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner