Provider Demographics
NPI:1982039970
Name:VAJARAKITIPONGSE, JESSICA GARDENIA (OTR)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GARDENIA
Last Name:VAJARAKITIPONGSE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:GARDENIA
Other - Last Name:ABAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:747 LASSEN DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-5980
Mailing Address - Country:US
Mailing Address - Phone:951-751-8612
Mailing Address - Fax:
Practice Address - Street 1:2815 S MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-2533
Practice Address - Country:US
Practice Address - Phone:951-475-1307
Practice Address - Fax:951-475-1308
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11386225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist