Healthcare Provider Details

I. General information

NPI: 1730207473
Provider Name (Legal Business Name): LISA L. JONG MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 GRAVES AVE
ROSEMEAD CA
91770-3414
US

IV. Provider business mailing address

PO BOX 1039
ROSEMEAD CA
91770-1000
US

V. Phone/Fax

Practice location:
  • Phone: 626-280-6510
  • Fax: 626-288-1026
Mailing address:
  • Phone: 626-280-6510
  • Fax: 626-288-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW16126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: