Provider Demographics
NPI:1083311930
Name:JELLISON, VANESSA RENEE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:RENEE
Last Name:JELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 N DUTTON AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4686
Mailing Address - Country:US
Mailing Address - Phone:707-568-2300
Mailing Address - Fax:
Practice Address - Street 1:1260 N DUTTON AVE STE 220
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4686
Practice Address - Country:US
Practice Address - Phone:707-568-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker