Provider Demographics
NPI:1861018392
Name:TRAN, JESSICA TIEN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:TIEN
Last Name:TRAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THUY TIEN
Other - Middle Name:THANH
Other - Last Name:TRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12521 KATHY LN
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5603
Mailing Address - Country:US
Mailing Address - Phone:714-722-5690
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2627
Practice Address - Country:US
Practice Address - Phone:909-634-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2023-05-15
Deactivation Date:2021-11-01
Deactivation Code:
Reactivation Date:2022-10-26
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician