Provider Demographics
NPI:1619507217
Name:SPEARS, JALISA NICOLE
Entity Type:Individual
Prefix:MS
First Name:JALISA
Middle Name:NICOLE
Last Name:SPEARS
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 1:5818 ZION RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-4579
Mailing Address - Country:US
Mailing Address - Phone:804-759-4050
Mailing Address - Fax:
Practice Address - Street 1:5818 ZION RIDGE DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-4579
Practice Address - Country:US
Practice Address - Phone:804-759-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty