Healthcare Provider Details

I. General information

NPI: 1861684417
Provider Name (Legal Business Name): JESSICA MARIE OBANA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-1329
US

IV. Provider business mailing address

6479 SEASCAPE DR
SAN DIEGO CA
92139-2325
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax: 858-626-8570
Mailing address:
  • Phone: 917-495-5457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number81354
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078435
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: