Provider Demographics
NPI:1386860625
Name:TISSIER, JEANNE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:M
Last Name:TISSIER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1786
Mailing Address - Street 2:
Mailing Address - City:HELENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:92342-1786
Mailing Address - Country:US
Mailing Address - Phone:760-242-5150
Mailing Address - Fax:
Practice Address - Street 1:18930 HIGHWAY18
Practice Address - Street 2:SUITE 106
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8369103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY8369OtherCALIF LIC