Provider Demographics
NPI:1174105175
Name:HUERTA, JESSICA MARICELA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARICELA
Last Name:HUERTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 DAWSON DR STE 1A
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8080
Mailing Address - Country:US
Mailing Address - Phone:805-384-1555
Mailing Address - Fax:
Practice Address - Street 1:391 DAWSON DR STE 1A
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8080
Practice Address - Country:US
Practice Address - Phone:805-384-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist