Jessica Briana Sample

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

19-155 Issued in CA

Practice address

1050 N Garey Ave
Pomona, CA 91767-3802

Phone

(909) 623-6391

Fax

(909) 620-9491

NPI assigned

Sep 4, 2019

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1567555200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1642032000000",
    "number": "1932758869",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1050 N GAREY AVE",
            "city": "POMONA",
            "state": "CA",
            "postal_code": "917673802",
            "telephone_number": "909-620-9491",
            "fax_number": "909-623-6391"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1050 N GAREY AVE",
            "city": "POMONA",
            "state": "CA",
            "postal_code": "917673802",
            "telephone_number": "909-623-6391",
            "fax_number": "909-620-9491"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SAMPLE",
        "first_name": "JESSICA",
        "middle_name": "BRIANA",
        "name_prefix": "Miss",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-09-04",
        "last_updated": "2022-01-13",
        "certification_date": "2022-01-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "CA",
            "license": "19-155",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "CA",
            "license": "19-155",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1023173135",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Mental Health Counselor in Pomona, CA
• Providers in Pomona, CA by specialty
• Mental Health Counselor in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.