Provider Demographics
NPI:1831613066
Name:WASSERMAN, JESSICA
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:WASSERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11323 E SAN RAPHAEL DRIVEWAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-8613
Mailing Address - Country:US
Mailing Address - Phone:760-668-2073
Mailing Address - Fax:
Practice Address - Street 1:545 LAUREL ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1634
Practice Address - Country:US
Practice Address - Phone:619-233-4399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program