Healthcare Provider Details

I. General information

NPI: 1508372871
Provider Name (Legal Business Name): LISA DEJONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 RANDOLPH ST
CALEDONIA IL
61011-9321
US

IV. Provider business mailing address

2311 RANDOLPH ST
CALEDONIA IL
61011-9321
US

V. Phone/Fax

Practice location:
  • Phone: 815-547-1977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1840449
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: