Provider Demographics
NPI:1992368476
Name:ALLE-CORLISS, JESSICA AMBER (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:AMBER
Last Name:ALLE-CORLISS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 E BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1906
Mailing Address - Country:US
Mailing Address - Phone:909-625-7207
Mailing Address - Fax:626-844-0481
Practice Address - Street 1:790 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1906
Practice Address - Country:US
Practice Address - Phone:909-625-7207
Practice Address - Fax:626-844-0481
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW914181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical