Healthcare Provider Details

I. General information

NPI: 1356047187
Provider Name (Legal Business Name): MARK JESINOSKI, PHD., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N MAIN AVE
FALLBROOK CA
92028
US

IV. Provider business mailing address

709 W COLLEGE ST
FALLBROOK CA
92028
US

V. Phone/Fax

Practice location:
  • Phone: 858-414-1141
  • Fax: 888-578-9808
Mailing address:
  • Phone: 858-923-5885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: KATHY O'NEAL
Title or Position: OFFICE MANAGER
Credential:
Phone: 858-414-1141