Provider Demographics
NPI:1033889845
Name:VAZQUEZ TAMES, JESSICA VANESSA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:VANESSA
Last Name:VAZQUEZ TAMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:VANESSA
Other - Last Name:TAMES GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1045 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5504
Mailing Address - Country:US
Mailing Address - Phone:619-235-2600
Mailing Address - Fax:
Practice Address - Street 1:1045 9TH AVE # 330
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5504
Practice Address - Country:US
Practice Address - Phone:619-235-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
CA137612106H00000X
CA150438106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3704Medicaid