Basic Information
| Provider Information | |||||||||
| NPI: | 1902062110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIZA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | STEPHANIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26051 GOVERNOR AVE | ||||||||
| Address2: | |||||||||
| City: | HARBOR CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907103204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108913674 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10929 SOUTH ST STE 208B | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907035368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629245526 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 28622 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 71344 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.