Basic Information
| Provider Information | |||||||||
| NPI: | 1780704411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOBLE | ||||||||
| FirstName: | JULISSA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CAODC-A-CS,LAADC-CA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOBLE | ||||||||
| OtherFirstName: | JULISSA | ||||||||
| OtherMiddleName: | B. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | 7169,LCI2840818 | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2591 OUTLOOK CV | ||||||||
| Address2: | |||||||||
| City: | PORT HUENEME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930411566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197799122 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2055 SAVIERS RD | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930333608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054832253 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 1612 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1780704411 | 05 | MA | MEDICAID | 1780704411 | 05 | CA | MEDICAID |