Provider Demographics
NPI:1124439211
Name:WATRY, JESSICA LEE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:WATRY
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 1:2275 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1132
Mailing Address - Country:US
Mailing Address - Phone:510-317-1444
Mailing Address - Fax:
Practice Address - Street 1:2178 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4535
Practice Address - Country:US
Practice Address - Phone:510-317-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125439106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist