Healthcare Provider Details

I. General information

NPI: 1679102016
Provider Name (Legal Business Name): JESSICA ROSE GILLESPIE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 09/13/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 S OAKLAND AVE STE 213
PASADENA CA
91101-2042
US

IV. Provider business mailing address

288 E LIVE OAK AVE # 125
ARCADIA CA
91006-5665
US

V. Phone/Fax

Practice location:
  • Phone: 626-708-0449
  • Fax:
Mailing address:
  • Phone: 626-708-0449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number98993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: