Provider Demographics
NPI:1922441286
Name:MEDINA, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MEDINA
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 1:8550 BALBOA BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-3562
Mailing Address - Country:US
Mailing Address - Phone:818-739-5109
Mailing Address - Fax:
Practice Address - Street 1:8550 BALBOA BLVD
Practice Address - Street 2:STE 150
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-3562
Practice Address - Country:US
Practice Address - Phone:818-739-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDI-CAL
CA7667OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7184OtherMEDI-CAL