Provider Demographics
NPI:1609690122
Name:SAMBRANO, JESSICA ICHA (MS, LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ICHA
Last Name:SAMBRANO
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12618 W INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6326
Mailing Address - Country:US
Mailing Address - Phone:480-748-9652
Mailing Address - Fax:
Practice Address - Street 1:7121 W BELL RD STE 240
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8559
Practice Address - Country:US
Practice Address - Phone:602-529-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-08232T101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health