Healthcare Provider Details

I. General information

NPI: 1225530231
Provider Name (Legal Business Name): JESSICA GOMEZ GUDINO MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S ANAHEIM BLVD STE 340
ANAHEIM CA
92805-3877
US

IV. Provider business mailing address

4221 WILSHIRE BLVD STE 300A
LOS ANGELES CA
90010-3537
US

V. Phone/Fax

Practice location:
  • Phone: 888-428-3223
  • Fax:
Mailing address:
  • Phone: 888-428-3223
  • Fax: 323-866-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-63796
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: