Healthcare Provider Details

I. General information

NPI: 1093287450
Provider Name (Legal Business Name): JESSICA DOSTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 N ANAHEIM BLVD
ANAHEIM CA
92805-2692
US

IV. Provider business mailing address

25002 REFLEJO
MISSION VIEJO CA
92692-2723
US

V. Phone/Fax

Practice location:
  • Phone: 714-776-7490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: