Provider Demographics
NPI:1720612260
Name:ESPANA, JULISSA ELIZABETH
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:ELIZABETH
Last Name:ESPANA
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 1:472 MCGRUE CIR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-3242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2970 HILLTOP MALL RD STE 104
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-1948
Practice Address - Country:US
Practice Address - Phone:510-243-5195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2021-09-14
Deactivation Date:2021-08-27
Deactivation Code:
Reactivation Date:2021-09-14
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician