=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265806673
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA VICKERS MA, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2015
-----------------------------------------------------
Last Update Date | 09/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 360 E 1ST ST # 4129
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-3211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-312-3920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8111 E CANDLEBERRY CIR
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92869-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-336-3836
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 89119
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------