=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902395130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANDREA MARCA MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2018
-----------------------------------------------------
Last Update Date | 03/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6631 STEPHENS RANCH RD
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-1146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-593-4926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24628 ZENA CT
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-282-9211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | ASW76609
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW104992
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------