Provider Demographics
NPI:1437811056
Name:HOMAIZAD, JESSICA LAUREN
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LAUREN
Last Name:HOMAIZAD
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 1:1508 CADDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-1845
Mailing Address - Country:US
Mailing Address - Phone:310-850-6876
Mailing Address - Fax:
Practice Address - Street 1:4525 E ATHERTON ST FL 2
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3700
Practice Address - Country:US
Practice Address - Phone:562-961-0155
Practice Address - Fax:562-961-0155
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW98850101YM0800X
CALCSW1238211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANCF10620087OtherANTHEM BLUE CROSS