Basic Information
| Provider Information | |||||||||
| NPI: | 1831432202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ERIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 S DE LACEY AVE | ||||||||
| Address2: | STE. 110 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263957100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 S DE LACEY AVE | ||||||||
| Address2: | STE. 110 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263957100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 10/12/2016 | ||||||||
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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 | 106H00000X | 74972 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.