Provider Demographics
NPI:1699499608
Name:DEL VALLE, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:DEL VALLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 VISITACION AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BRISBANE
Mailing Address - State:CA
Mailing Address - Zip Code:94005-1575
Mailing Address - Country:US
Mailing Address - Phone:415-528-0022
Mailing Address - Fax:
Practice Address - Street 1:44 VISITACION AVE STE 102
Practice Address - Street 2:
Practice Address - City:BRISBANE
Practice Address - State:CA
Practice Address - Zip Code:94005-1575
Practice Address - Country:US
Practice Address - Phone:415-528-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3179321172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver