MEDICARE: JESSICA KARAS WATERSON L.M.F.T

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC#53753	CA

General Provider Information

NPI Number	:	1376966515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA KARAS WATERSON L.M.F.T

Provider Business Mailing Address
First Line	:	427 YALE AVE # 202
Second Line	:
City	:	CLAREMONT
State	:	CA
Zip	:	91711-4340
Country	:	US
Telephone Number	:	619-818-6165
Fax Number	:

Provider Business Practice Location Address
First Line	:	3999 OLD TOWN AVE # B-100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-2964
Country	:	US
Telephone Number	:	619-818-6165
Fax Number	:	619-299-9089

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2014
Last Update Date	:	12/28/2021

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