Provider Demographics
NPI:1689309676
Name:VANDERWOOD, JESSICA VICTORIA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:VICTORIA
Last Name:VANDERWOOD
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 1:31051 E SUNSET DR N
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7454
Mailing Address - Country:US
Mailing Address - Phone:832-374-6061
Mailing Address - Fax:
Practice Address - Street 1:21600 OXNARD ST STE 1030
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-5085
Practice Address - Country:US
Practice Address - Phone:877-206-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician