Healthcare Provider Details

I. General information

NPI: 1386574358
Provider Name (Legal Business Name): JESSICA NIMIE MA, EDS, PPS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13010 PASEO LUCIDO
SAN DIEGO CA
92128-4499
US

IV. Provider business mailing address

15250 AVENUE OF SCIENCE
SAN DIEGO CA
92128-3406
US

V. Phone/Fax

Practice location:
  • Phone: 858-485-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: