Healthcare Provider Details

I. General information

NPI: 1356624688
Provider Name (Legal Business Name): LAISA CHEANG JAMISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 RIVERVIEW DR
JURUPA VALLEY CA
92509-6611
US

IV. Provider business mailing address

3924 RIVERVIEW DR
RIVERSIDE CA
92509-6611
US

V. Phone/Fax

Practice location:
  • Phone: 951-360-4175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW37050
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberASW37050
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number76427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: