Provider Demographics
NPI:1891040986
Name:AYSANOA, JESSICA (BS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:AYSANOA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9214 DOROTHY LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-1618
Mailing Address - Country:US
Mailing Address - Phone:703-910-4362
Mailing Address - Fax:703-910-4367
Practice Address - Street 1:12656 LAKE RIDGE DR STE C
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-7504
Practice Address - Country:US
Practice Address - Phone:703-910-4362
Practice Address - Fax:703-910-4367
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst