Provider Demographics
NPI:1912542903
Name:TYSON, JILLIAN LEE (MA)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEE
Last Name:TYSON
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 1:1170 INDUSTRIAL ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0734
Mailing Address - Country:US
Mailing Address - Phone:530-722-9957
Mailing Address - Fax:
Practice Address - Street 1:1170 INDUSTRIAL ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0734
Practice Address - Country:US
Practice Address - Phone:530-755-9957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA128916106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist