Provider Demographics
NPI:1215782297
Name:KILBURN, JESSICA ROSE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:KILBURN
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:PO BOX 251971
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-9077
Mailing Address - Country:US
Mailing Address - Phone:310-430-5683
Mailing Address - Fax:
Practice Address - Street 1:947 15TH ST APT 3
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-3132
Practice Address - Country:US
Practice Address - Phone:310-430-5683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1052151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical