Provider Demographics
NPI:1063649325
Name:JARVIS, KELLI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:
Last Name:JARVIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12575 NEWPORT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2451
Mailing Address - Country:US
Mailing Address - Phone:714-851-0323
Mailing Address - Fax:
Practice Address - Street 1:12575 NEWPORT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2451
Practice Address - Country:US
Practice Address - Phone:714-851-0323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-14
Last Update Date:2012-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46102106H00000X
CA25061103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist