Provider Demographics
NPI:1679923593
Name:CERASOLI, JESSICA (LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CERASOLI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 FELIX ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4809
Mailing Address - Country:US
Mailing Address - Phone:775-544-2607
Mailing Address - Fax:
Practice Address - Street 1:2244 BARTON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3408
Practice Address - Country:US
Practice Address - Phone:530-542-9355
Practice Address - Fax:530-541-9350
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16786171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist