Provider Demographics
NPI:1316675861
Name:HEADLEY, JENESSA
Entity type:Individual
Prefix:
First Name:JENESSA
Middle Name:
Last Name:HEADLEY
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 1:683 LAXFORD RD
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-6532
Mailing Address - Country:US
Mailing Address - Phone:951-692-8407
Mailing Address - Fax:
Practice Address - Street 1:683 LAXFORD RD
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-6532
Practice Address - Country:US
Practice Address - Phone:951-692-8407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA887521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical