Healthcare Provider Details

I. General information

NPI: 1467938688
Provider Name (Legal Business Name): JESSICA IVETT ANDRADE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 PENINSULA AVE
SAN MATEO CA
94401-1653
US

IV. Provider business mailing address

2048 MILLER AVE
MODESTO CA
95354-2925
US

V. Phone/Fax

Practice location:
  • Phone: 650-289-4396
  • Fax:
Mailing address:
  • Phone: 209-289-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: