Provider Demographics
NPI:1134401805
Name:TAVERNITI, JESSICA L (PSYD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:L
Last Name:TAVERNITI
Suffix:
Gender:F
Credentials:PSYD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 LA JOLLA BLVD UNIT 142
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-6633
Mailing Address - Country:US
Mailing Address - Phone:406-570-6184
Mailing Address - Fax:
Practice Address - Street 1:10855 SORRENTO VALLEY RD STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1615
Practice Address - Country:US
Practice Address - Phone:619-800-8145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-8560103K00000X
CAPSY 26598103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPSY-PSY-LIC-3580OtherPSYCHOLOGY BOARD
CAPSY 26598OtherPSYCHOLOGY BOARD
1-11-8560OtherBEHAVIOR ANALYST CERTIFICATION BOARD