Provider Demographics
NPI:1366893190
Name:MOTA, JESSICA VIANNEY (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:VIANNEY
Last Name:MOTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:VIANNEY
Other - Last Name:ROMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1336 BRIDGEGATE DR FL 2
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1336 BRIDGEGATE DR FL 2
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3955
Practice Address - Country:US
Practice Address - Phone:909-781-4618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X, 390200000X
CA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program