Provider Demographics
NPI:1316417017
Name:PERALES, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PERALES
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 1:719 HARVEST MILL DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-8359
Mailing Address - Country:US
Mailing Address - Phone:209-640-3492
Mailing Address - Fax:
Practice Address - Street 1:1111 W TOKAY ST STE A
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3965
Practice Address - Country:US
Practice Address - Phone:209-640-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAAPCC12778390200000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAPCC12778OtherBOARD OF BEHAVIORAL SCIENCE