Healthcare Provider Details

I. General information

NPI: 1689217705
Provider Name (Legal Business Name): KRISTA MARIE JESSIE APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTA MARIE TARVIN APCC

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 W SHAW AVE STE 107
FRESNO CA
93711-3201
US

IV. Provider business mailing address

3554 N DUKE AVE SPC 136
FRESNO CA
93727-7833
US

V. Phone/Fax

Practice location:
  • Phone: 559-515-6180
  • Fax:
Mailing address:
  • Phone: 559-618-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: