Provider Demographics
NPI:1124351390
Name:KUBOTA, JESSICA C
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:C
Last Name:KUBOTA
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 1:7600 E GRAVES AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3414
Mailing Address - Country:US
Mailing Address - Phone:626-280-6510
Mailing Address - Fax:
Practice Address - Street 1:7600 E GRAVES AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-3414
Practice Address - Country:US
Practice Address - Phone:626-280-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMFT 62970106H00000X
CA77131106H00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner