Provider Demographics
NPI:1801315734
Name:PLATA, JAMIE CARISSA D
Entity type:Individual
Prefix:
First Name:JAMIE CARISSA
Middle Name:D
Last Name:PLATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE CARISSA
Other - Middle Name:M
Other - Last Name:DE LA CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:329 E CALIFORNIA BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 N SANTA ANITA AVE STE 105
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3157
Practice Address - Country:US
Practice Address - Phone:626-623-6355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47992355S0801X
CA14044235Z00000X
CA30771235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant