Provider Demographics
NPI:1578379277
Name:RICHARDSON, JESSICA DANIELLE (NP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DANIELLE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:DANIELLE
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3150 FLORINE DR APT B
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-2119
Mailing Address - Country:US
Mailing Address - Phone:636-448-9339
Mailing Address - Fax:
Practice Address - Street 1:9888 CARROLL CENTRE RD STE 218A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4515
Practice Address - Country:US
Practice Address - Phone:858-935-9104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032874363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health