Basic Information
| Provider Information | |||||||||
| NPI: | 1104121342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLSTON | ||||||||
| FirstName: | JESSECA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.A., LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 321 CASSIDY ST | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920545314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607212171 | ||||||||
| FaxNumber: | 7607218582 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 ALLEGHANY LOOP | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234562442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583490873 | ||||||||
| FaxNumber: | 8583490873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2011 | ||||||||
| LastUpdateDate: | 03/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 0717001507 | VA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 95098 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.