Provider Demographics
NPI:1154960029
Name:CHHOUM, JESSIE L
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:L
Last Name:CHHOUM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JESSIE
Other - Middle Name:L
Other - Last Name:CHHOUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7986 DAGGET ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-2321
Mailing Address - Country:US
Mailing Address - Phone:858-300-0460
Mailing Address - Fax:
Practice Address - Street 1:7986 DAGGET ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2321
Practice Address - Country:US
Practice Address - Phone:858-300-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-24
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty