Provider Demographics
NPI:1629441639
Name:MENDOZA-MIRANDA, JESSICA LISBET
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LISBET
Last Name:MENDOZA-MIRANDA
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 1:273 TUNIS RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94603-1061
Mailing Address - Country:US
Mailing Address - Phone:510-603-4868
Mailing Address - Fax:877-905-8222
Practice Address - Street 1:273 TUNIS RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94603-1061
Practice Address - Country:US
Practice Address - Phone:510-603-4868
Practice Address - Fax:877-905-8222
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125266106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist