Healthcare Provider Details

I. General information

NPI: 1679930127
Provider Name (Legal Business Name): JESSICA PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CIVIC PLAZA DR FL 3
CARSON CA
90745-2243
US

IV. Provider business mailing address

1 CIVIC PLAZA DR FL 3
CARSON CA
90745-2243
US

V. Phone/Fax

Practice location:
  • Phone: 310-233-1623
  • Fax:
Mailing address:
  • Phone: 310-233-1623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW83060
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number83060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: