Healthcare Provider Details

I. General information

NPI: 1376813717
Provider Name (Legal Business Name): JESSICA PRICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

IV. Provider business mailing address

1594 VIA CAPRI #10
LAGUNA BEACH CA
92651
US

V. Phone/Fax

Practice location:
  • Phone: 562-485-3064
  • Fax:
Mailing address:
  • Phone: 480-203-1583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW28972
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW71145
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW71145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: