Healthcare Provider Details

I. General information

NPI: 1255411443
Provider Name (Legal Business Name): JONELLE LEE SELLERS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CITY DRIVE
ORANGE CA
92668
US

IV. Provider business mailing address

PO BOX 7244
ORANGE CA
92863-7244
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-7030
  • Fax:
Mailing address:
  • Phone: 714-935-7030
  • Fax: 714-935-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number17569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: