Basic Information
| Provider Information | |||||||||
| NPI: | 1891378865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 677 PORTER ST | ||||||||
| Address2: | |||||||||
| City: | FALLBROOK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920281581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602087131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2141 PALOMAR AIRPT RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607102460 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2021 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | N | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.