Provider Demographics
NPI:1699364893
Name:CARLSON, JESSICA R
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:R
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93033-3059
Mailing Address - Country:US
Mailing Address - Phone:805-946-4187
Mailing Address - Fax:
Practice Address - Street 1:1401 W ELM ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033-3059
Practice Address - Country:US
Practice Address - Phone:805-946-4187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician