Healthcare Provider Details

I. General information

NPI: 1497169890
Provider Name (Legal Business Name): JESSICA MOYA LCSW 67422
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12450 VAN NUYS BLVD SUITE 200
PACOIMA CA
91331-1391
US

IV. Provider business mailing address

12450 VAN NUYS BLVD SUITE 200
PACOIMA CA
91331-1391
US

V. Phone/Fax

Practice location:
  • Phone: 818-896-1161
  • Fax: 818-896-5069
Mailing address:
  • Phone: 818-896-1161
  • Fax: 818-896-5069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number67422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: