Healthcare Provider Details

I. General information

NPI: 1972481372
Provider Name (Legal Business Name): JESSICA DIANDRA OBRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PETALUMA BLVD S
PETALUMA CA
94952-5545
US

IV. Provider business mailing address

1036 KAWANA SPRINGS RD APT 206
SANTA ROSA CA
95404-1866
US

V. Phone/Fax

Practice location:
  • Phone: 707-765-8488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: