Basic Information
| Provider Information | |||||||||
| NPI: | 1447800743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNAL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DOLORES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900372729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132235922 | ||||||||
| FaxNumber: | 3238915344 | ||||||||
| Practice Location | |||||||||
| Address1: | 14659 OLIVE VIEW DR | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913421652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184850888 | ||||||||
| FaxNumber: | 8188335690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2019 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 95974 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.