Provider Demographics
NPI:1508372871
Name:DEJONG, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DEJONG
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 1:2311 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:IL
Mailing Address - Zip Code:61011-9321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2311 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:IL
Practice Address - Zip Code:61011-9321
Practice Address - Country:US
Practice Address - Phone:815-547-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1840449103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool