Provider Demographics
NPI:1861684417
Name:OBANA, JESSICA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:OBANA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6479 SEASCAPE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-2325
Mailing Address - Country:US
Mailing Address - Phone:917-495-5457
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-1329
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:858-626-8570
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA813541041C0700X
NY0784351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY078435OtherNEW YORK LCSW
CA81354OtherCALIFORNIA LCSW