Provider Demographics
NPI:1104334010
Name:SALAZAR, JESSY NAYELI (BA)
Entity type:Individual
Prefix:
First Name:JESSY
Middle Name:NAYELI
Last Name:SALAZAR
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 HEATHER AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6609
Mailing Address - Country:US
Mailing Address - Phone:714-856-8211
Mailing Address - Fax:
Practice Address - Street 1:18008 SKY PARK CIR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6433
Practice Address - Country:US
Practice Address - Phone:949-474-1493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician