Provider Demographics
NPI:1821696097
Name:JONES, LARISSA NICHOLE
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:NICHOLE
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 1:505 E TRAVIS ST STE 208
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-4281
Mailing Address - Country:US
Mailing Address - Phone:832-562-8255
Mailing Address - Fax:
Practice Address - Street 1:505 E TRAVIS ST STE 208
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-4281
Practice Address - Country:US
Practice Address - Phone:832-562-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor