Healthcare Provider Details

I. General information

NPI: 1457869521
Provider Name (Legal Business Name): JESSICA GASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MISSION CENTER RD STE 110
SAN DIEGO CA
92108-1347
US

IV. Provider business mailing address

16782 VON KARMAN AVE STE 11
IRVINE CA
92606-2417
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax: 619-374-7134
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-61817
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-28728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: