Healthcare Provider Details

I. General information

NPI: 1154914539
Provider Name (Legal Business Name): JESSLY GUADALUPE ROSALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44840 VALLEY CENTRAL WAY STE 102
LANCASTER CA
93536-7261
US

IV. Provider business mailing address

40710 168TH ST E
LANCASTER CA
93535-7109
US

V. Phone/Fax

Practice location:
  • Phone: 661-592-0701
  • Fax:
Mailing address:
  • Phone: 626-315-8341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number8367
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: