Provider Demographics
NPI:1679389928
Name:WEAVER, JESSICA MARILYN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARILYN
Last Name:WEAVER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-4709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 S CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-4709
Practice Address - Country:US
Practice Address - Phone:559-453-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CAAMFT140209106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist