Healthcare Provider Details

I. General information

NPI: 1215856554
Provider Name (Legal Business Name): JESSICA MARIANE PATRICIO REZENDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA REZENDE TRAINEE

II. Dates (important events)

Enumeration Date: 07/11/2026
Last Update Date: 07/11/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 EDITH ST
PETALUMA CA
94952-3272
US

IV. Provider business mailing address

64 EDITH ST
PETALUMA CA
94952-3272
US

V. Phone/Fax

Practice location:
  • Phone: 707-364-6050
  • Fax:
Mailing address:
  • Phone: 707-364-6050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: