Provider Demographics
NPI:1760716039
Name:WILLIS, JOETTA KAY (MA)
Entity Type:Individual
Prefix:MRS
First Name:JOETTA
Middle Name:KAY
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-1462
Mailing Address - Country:US
Mailing Address - Phone:916-996-9736
Mailing Address - Fax:
Practice Address - Street 1:1609 N WILSON WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-3119
Practice Address - Country:US
Practice Address - Phone:209-639-4935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-19
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT52986106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist