Provider Demographics
NPI:1710639869
Name:ANDERSON, JESSICA STORY
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:STORY
Last Name:ANDERSON
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 1:964 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6102
Mailing Address - Country:US
Mailing Address - Phone:858-255-1658
Mailing Address - Fax:833-536-2427
Practice Address - Street 1:964 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6102
Practice Address - Country:US
Practice Address - Phone:858-255-1658
Practice Address - Fax:833-536-2427
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW612951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical