Healthcare Provider Details

I. General information

NPI: 1306300512
Provider Name (Legal Business Name): ELISE N JARVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 SALT POND RD STE H1
WAKEFIELD RI
02879-4337
US

IV. Provider business mailing address

39 MERINO ST
JOHNSTON RI
02919-4417
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-3694
  • Fax:
Mailing address:
  • Phone: 973-600-2769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC01020
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: