=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245787779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA M NOLASCO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 05/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 WILSHIRE BLVD SUITE 300
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-481-7464
-----------------------------------------------------
Fax | 213-481-7147
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 9TH AVE
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98104-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-744-5508
-----------------------------------------------------
Fax | 206-744-5138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | ASW62554
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------