1386862910 NPI number — MISS JESSICA MARISOL MORENO INTERN LCSW

Table of content: MISS JESSICA MARISOL MORENO INTERN LCSW (NPI 1386862910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386862910 NPI number — MISS JESSICA MARISOL MORENO INTERN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
JESSICA
Provider Middle Name:
MARISOL
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
INTERN LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386862910
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
566 S BRAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FERNANDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91340-4002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-836-4180
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
566 S BRAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FERNANDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91340-4002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-898-0223
Provider Business Practice Location Address Fax Number:
818-361-5384
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com