Provider Demographics
NPI:1538263579
Name:JELLISON, LISA ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:JELLISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 SOUTHBURY LN
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-8207
Mailing Address - Country:US
Mailing Address - Phone:530-898-9008
Mailing Address - Fax:530-898-9008
Practice Address - Street 1:5 GOVERNORS LN
Practice Address - Street 2:SUITE 150
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-5504
Practice Address - Country:US
Practice Address - Phone:530-898-9008
Practice Address - Fax:530-898-9008
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA192401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18489ZOtherPTAN