Provider Demographics
NPI:1629690334
Name:JONES, CARRISSA MICHELLE DAINO
Entity Type:Individual
Prefix:
First Name:CARRISSA
Middle Name:MICHELLE DAINO
Last Name:JONES
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 1:1638 HUNTINGTON DR APT D
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4741
Mailing Address - Country:US
Mailing Address - Phone:916-690-2404
Mailing Address - Fax:
Practice Address - Street 1:3680 E IMPERIAL HWY STE 220
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2663
Practice Address - Country:US
Practice Address - Phone:323-769-7174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128934101YM0800X
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health