Healthcare Provider Details

I. General information

NPI: 1134401805
Provider Name (Legal Business Name): JESSICA L TAVERNITI PSY.D, BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10855 SORRENTO VALLEY RD STE 204
SAN DIEGO CA
92121-1615
US

IV. Provider business mailing address

6455 LA JOLLA BLVD UNIT 142
LA JOLLA CA
92037-6633
US

V. Phone/Fax

Practice location:
  • Phone: 619-800-8145
  • Fax:
Mailing address:
  • Phone: 406-570-6184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 26598
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-8560
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: