Healthcare Provider Details

I. General information

NPI: 1063649325
Provider Name (Legal Business Name): KELLI JARVIS PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2009
Last Update Date: 11/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12575 NEWPORT AVE SUITE A
TUSTIN CA
92780-2451
US

IV. Provider business mailing address

12575 NEWPORT AVE SUITE A
TUSTIN CA
92780-2451
US

V. Phone/Fax

Practice location:
  • Phone: 714-851-0323
  • Fax:
Mailing address:
  • Phone: 714-851-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25061
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number46102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: