Healthcare Provider Details

I. General information

NPI: 1902258403
Provider Name (Legal Business Name): JESSICA FAYE TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11721 TELEGRAPH RD BUILDING G
SANTA FE SPRINGS CA
90670-3674
US

IV. Provider business mailing address

11721 TELEGRAPH RD BUILDING G
SANTA FE SPRINGS CA
90670-3674
US

V. Phone/Fax

Practice location:
  • Phone: 562-949-8455
  • Fax:
Mailing address:
  • Phone: 562-949-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW78274
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: