Provider Demographics
NPI:1942683933
Name:LUGO, JESSICA ZAMORA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ZAMORA
Last Name:LUGO
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 1:1221 E DYER RD
Mailing Address - Street 2:SUITE#220
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5600
Mailing Address - Country:US
Mailing Address - Phone:714-323-0473
Mailing Address - Fax:
Practice Address - Street 1:16580 HARBOR BLVD STE M
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1385
Practice Address - Country:US
Practice Address - Phone:714-504-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health