Provider Demographics
NPI:1205121480
Name:DAUGHERTY, JENESSA PASCOE (MA)
Entity type:Individual
Prefix:
First Name:JENESSA
Middle Name:PASCOE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 REGENTS RD
Mailing Address - Street 2:APT 301
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1376
Mailing Address - Country:US
Mailing Address - Phone:619-736-9117
Mailing Address - Fax:
Practice Address - Street 1:8202 REGENTS RD
Practice Address - Street 2:APT 301
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1376
Practice Address - Country:US
Practice Address - Phone:619-736-9117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60224970101YM0800X
CA96860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health