Basic Information
| Provider Information | |||||||||
| NPI: | 1790211712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAYLE-THOMAS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1180 THIRD AVE STE C3 | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919113139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196918164 | ||||||||
| FaxNumber: | 6194262359 | ||||||||
| Practice Location | |||||||||
| Address1: | 1180 THIRD AVE STE C3 | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919113139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196918164 | ||||||||
| FaxNumber: | 6194262359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YA0400X | R1418710221 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.