Healthcare Provider Details

I. General information

NPI: 1609302496
Provider Name (Legal Business Name): JYLL LYSOBEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 OCEAN VIEW AVE
PISMO BEACH CA
93449-2516
US

IV. Provider business mailing address

350 OCEAN VIEW AVE
PISMO BEACH CA
93449-2516
US

V. Phone/Fax

Practice location:
  • Phone: 805-709-7720
  • Fax:
Mailing address:
  • Phone: 805-709-7720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number86871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: