Provider Demographics
NPI:1891378865
Name:WHITE, JESSICA LYN (MS)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-1581
Mailing Address - Country:US
Mailing Address - Phone:760-208-7131
Mailing Address - Fax:
Practice Address - Street 1:677 PORTER ST
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-1581
Practice Address - Country:US
Practice Address - Phone:760-208-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X, 247200000X
CA1-22-57573103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other