Healthcare Provider Details

I. General information

NPI: 1881557767
Provider Name (Legal Business Name): JESSE TALLYEN LMSW, LCDP, CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 COOPER ST
LAUREL DE
19956-1731
US

IV. Provider business mailing address

529 COOPER ST
LAUREL DE
19956-1731
US

V. Phone/Fax

Practice location:
  • Phone: 302-569-5114
  • Fax:
Mailing address:
  • Phone: 302-569-5114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberQ3-0011153
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCD-0010151
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: