Provider Demographics
NPI:1669966628
Name:GAINES, JESSICA (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GAINES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 RANCHO VIEJO DR
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-4236
Mailing Address - Country:US
Mailing Address - Phone:619-917-2530
Mailing Address - Fax:
Practice Address - Street 1:355 SANTA FE DR STE 200
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5153
Practice Address - Country:US
Practice Address - Phone:760-635-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28223103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical