Healthcare Provider Details

I. General information

NPI: 1770953184
Provider Name (Legal Business Name): JESSICA CUELLAR PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 MIRANDA AVE
PALO ALTO CA
94304-1207
US

IV. Provider business mailing address

PO BOX 372
BELMONT CA
94002-0372
US

V. Phone/Fax

Practice location:
  • Phone: 650-530-0223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27633
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: