Healthcare Provider Details

I. General information

NPI: 1588117808
Provider Name (Legal Business Name): JESSICA NOELLE PANOSKI ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 LOS GAMOS
SAN RAFAEL CA
95403
US

IV. Provider business mailing address

2255 CHALLENGER WAY STE 107
SANTA ROSA CA
95407-5423
US

V. Phone/Fax

Practice location:
  • Phone: 415-328-1142
  • Fax:
Mailing address:
  • Phone: 707-565-4797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: