Healthcare Provider Details

I. General information

NPI: 1982957361
Provider Name (Legal Business Name): ABBY JANE-MARIE CORDOVA MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6472 BOULDER LAKE AVE
SAN DIEGO CA
92119-3142
US

IV. Provider business mailing address

8898 NAVAJO ROAD SUITE C #152
SAN DIEGO CA
92119-3142
US

V. Phone/Fax

Practice location:
  • Phone: 925-487-0614
  • Fax:
Mailing address:
  • Phone: 925-487-0614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 51650
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC51650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: