1265806673 NPI number — JESSICA VICKERS MA, LMFT

Table of content: JESSICA VICKERS MA, LMFT (NPI 1265806673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265806673 NPI number — JESSICA VICKERS MA, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VICKERS
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CYRUS
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, LMFT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1265806673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8111 E CANDLEBERRY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92869-4527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-336-3836
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 E 1ST ST # 4129
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-3211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-312-3920
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2015

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: 106H00000X , with the licence number:  89119 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LMFT89119 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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