Provider Demographics
NPI:1770230237
Name:DEJESUS, SHANNON YANDALL (AMFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:YANDALL
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 ROBINSON AVE STE 204D
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-7634
Mailing Address - Country:US
Mailing Address - Phone:619-630-5557
Mailing Address - Fax:
Practice Address - Street 1:1807 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-7633
Practice Address - Country:US
Practice Address - Phone:619-630-5557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128629101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health