Provider Demographics
NPI:1992174965
Name:LARA, JESSICA APRIL (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:APRIL
Last Name:LARA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:APRIL
Other - Last Name:FOUKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:801 CRESCENT WAY STE 4
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6781
Mailing Address - Country:US
Mailing Address - Phone:707-677-8200
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:801 CRESCENT WAY STE 4
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6781
Practice Address - Country:US
Practice Address - Phone:707-677-8200
Practice Address - Fax:707-826-8638
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30688103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program