Healthcare Provider Details

I. General information

NPI: 1124253307
Provider Name (Legal Business Name): JONATHAN MARC WALLIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: J. MARC WALLIS LCSW

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 SCOTT ST
SAN FRANCISCO CA
94115-3014
US

IV. Provider business mailing address

1610 SCOTT ST
SAN FRANCISCO CA
94115-3014
US

V. Phone/Fax

Practice location:
  • Phone: 415-820-9609
  • Fax:
Mailing address:
  • Phone: 415-820-9609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS19858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: