Provider Demographics
NPI:1154914539
Name:ROSALES, JESSLY GUADALUPE
Entity type:Individual
Prefix:
First Name:JESSLY
Middle Name:GUADALUPE
Last Name:ROSALES
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 1:40710 168TH ST E
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-7109
Mailing Address - Country:US
Mailing Address - Phone:626-315-8341
Mailing Address - Fax:
Practice Address - Street 1:44840 VALLEY CENTRAL WAY STE 102
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-7261
Practice Address - Country:US
Practice Address - Phone:661-592-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA83672355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician