Provider Demographics
NPI:1043962319
Name:JONES, CALLIE L (SUDRC #12472)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:L
Last Name:JONES
Suffix:
Gender:F
Credentials:SUDRC #12472
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N G ST APT F
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-4153
Mailing Address - Country:US
Mailing Address - Phone:805-588-0040
Mailing Address - Fax:
Practice Address - Street 1:104 S C ST STE A
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6924
Practice Address - Country:US
Practice Address - Phone:805-588-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)