Provider Demographics
NPI:1790029700
Name:CORRAL, JESSI NICOLE
Entity Type:Individual
Prefix:
First Name:JESSI
Middle Name:NICOLE
Last Name:CORRAL
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 1:3441 DATA DR APT 406
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7998
Mailing Address - Country:US
Mailing Address - Phone:415-497-1649
Mailing Address - Fax:
Practice Address - Street 1:9470 MICRON AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2612
Practice Address - Country:US
Practice Address - Phone:916-947-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CA989341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician