Healthcare Provider Details

I. General information

NPI: 1528820008
Provider Name (Legal Business Name): AMY ALYSSA JILLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 ALTA RD UNIT 6100
SAN DIEGO CA
92158-0001
US

IV. Provider business mailing address

441 ALTA RD
SAN DIEGO CA
92101
US

V. Phone/Fax

Practice location:
  • Phone: 858-285-6020
  • Fax:
Mailing address:
  • Phone: 858-285-6020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number144742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: