Provider Demographics
NPI:1467238840
Name:ROTHWELL, JESSICA RYAN-GRAVES
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RYAN-GRAVES
Last Name:ROTHWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RYAN
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 32392
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95152-2392
Mailing Address - Country:US
Mailing Address - Phone:214-326-9633
Mailing Address - Fax:
Practice Address - Street 1:2087 LIMEWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-1234
Practice Address - Country:US
Practice Address - Phone:214-326-9633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18119101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator