Provider Demographics
NPI:1831658392
Name:PEREZ, JESSICA JORDAN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JORDAN
Last Name:PEREZ
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:PO BOX 8952
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-8952
Mailing Address - Country:US
Mailing Address - Phone:925-354-4452
Mailing Address - Fax:
Practice Address - Street 1:1266 14TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2247
Practice Address - Country:US
Practice Address - Phone:510-273-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CA112786106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800YMedicaid
CA101YM0800XMedicaid