Provider Demographics
NPI:1245046168
Name:DEATHERAGE, JESSICA LYNN (MC TRAINEE)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:DEATHERAGE
Suffix:
Gender:F
Credentials:MC TRAINEE
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8740 GILARDI RD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9341
Mailing Address - Country:US
Mailing Address - Phone:916-617-9749
Mailing Address - Fax:
Practice Address - Street 1:1275 HIGH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-5016
Practice Address - Country:US
Practice Address - Phone:530-264-8804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional