Provider Demographics
NPI:1942012380
Name:BLAIR, JEANESSA
Entity type:Individual
Prefix:
First Name:JEANESSA
Middle Name:
Last Name:BLAIR
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 1:22 ALCOTT ST
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-1238
Mailing Address - Country:US
Mailing Address - Phone:310-901-2564
Mailing Address - Fax:
Practice Address - Street 1:17350 MOUNT HERRMANN ST STE A
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4114
Practice Address - Country:US
Practice Address - Phone:310-901-2564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT119702106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist