Healthcare Provider Details

I. General information

NPI: 1083311930
Provider Name (Legal Business Name): VANESSA RENEE JELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 STONY POINT RD STE 210
SANTA ROSA CA
95401-4118
US

IV. Provider business mailing address

110 STONY POINT RD STE 210
SANTA ROSA CA
95401-4118
US

V. Phone/Fax

Practice location:
  • Phone: 707-890-3800
  • Fax:
Mailing address:
  • Phone: 707-890-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: