Provider Demographics
NPI:1356869648
Name:CORENA, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CORENA
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 1:6454 VAN NUYS BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1445
Mailing Address - Country:US
Mailing Address - Phone:213-361-0315
Mailing Address - Fax:
Practice Address - Street 1:6454 VAN NUYS BLVD STE 111
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1445
Practice Address - Country:US
Practice Address - Phone:213-361-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33977103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical