Healthcare Provider Details

I. General information

NPI: 1932565686
Provider Name (Legal Business Name): JESSICA KARINA MARROQUIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 TOWNSGATE RD
THOUSAND OAKS CA
91361-5751
US

IV. Provider business mailing address

6160 CORNERSTONE CT E STE 100
SAN DIEGO CA
92121-3724
US

V. Phone/Fax

Practice location:
  • Phone: 800-413-3009
  • Fax: 805-413-4462
Mailing address:
  • Phone: 858-216-8837
  • Fax: 619-941-0276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number135762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: