Provider Demographics
NPI:1992245914
Name:CHILES, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CHILES
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 1:16661 VENTURA BLVD
Mailing Address - Street 2:SUITE #400-F
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1914
Mailing Address - Country:US
Mailing Address - Phone:310-985-1160
Mailing Address - Fax:
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:SUITE #400-F
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1914
Practice Address - Country:US
Practice Address - Phone:310-985-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94023229103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist