Healthcare Provider Details

I. General information

NPI: 1952735938
Provider Name (Legal Business Name): JESSICA ERNANDES NAECKER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA ANN ERNANDES

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HIGH BLUFF DR STE 104
SAN DIEGO CA
92130
US

IV. Provider business mailing address

14023 MANGO DR APT H
DEL MAR CA
92014-2965
US

V. Phone/Fax

Practice location:
  • Phone: 858-209-0797
  • Fax:
Mailing address:
  • Phone: 858-209-0797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3739
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: