Provider Demographics
NPI:1710694021
Name:KEYS, JESSICA JUNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JUNE
Last Name:KEYS
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 1:320 PINE AVE STE 609
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-2310
Mailing Address - Country:US
Mailing Address - Phone:562-279-0180
Mailing Address - Fax:562-661-9672
Practice Address - Street 1:320 PINE AVE STE 609
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-2310
Practice Address - Country:US
Practice Address - Phone:562-279-0180
Practice Address - Fax:562-661-9672
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X, 101YM0800X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000000000Other0000