Basic Information
| Provider Information | |||||||||
| NPI: | 1831613066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASSERMAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11323 E SAN RAPHAEL DRIVEWAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921308613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606682073 | ||||||||
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| Practice Location | |||||||||
| Address1: | 545 LAUREL ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921011634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192334399 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2017 | ||||||||
| LastUpdateDate: | 07/31/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.