Provider Demographics
NPI:1457400400
Name:JESSUM, RHONDA LEE (PHD)
Entity type:Individual
Prefix:
First Name:RHONDA
Middle Name:LEE
Last Name:JESSUM
Suffix:
Gender:F
Credentials:PHD
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 1027
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-1027
Mailing Address - Country:US
Mailing Address - Phone:818-880-0250
Mailing Address - Fax:
Practice Address - Street 1:3198 GORGE RD
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-3518
Practice Address - Country:US
Practice Address - Phone:818-880-0250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15775103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15775Medicare ID - Type UnspecifiedMEDICARE IDENITIFICATION