Provider Demographics
NPI:1285777359
Name:DEJAIFRE, JESSICA KAY (MFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KAY
Last Name:DEJAIFRE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25042 ANDREO AVE
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-1710
Mailing Address - Country:US
Mailing Address - Phone:310-245-0917
Mailing Address - Fax:
Practice Address - Street 1:370 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1727
Practice Address - Country:US
Practice Address - Phone:310-787-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39667106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist