Healthcare Provider Details

I. General information

NPI: 1467154237
Provider Name (Legal Business Name): JESSICA MARLENE WALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 TELEPHONE RD STE 117
VENTURA CA
93003-5672
US

IV. Provider business mailing address

4601 TELEPHONE RD STE 117
VENTURA CA
93003-5672
US

V. Phone/Fax

Practice location:
  • Phone: 820-732-6393
  • Fax:
Mailing address:
  • Phone: 805-852-1906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: