Provider Demographics
NPI:1558925172
Name:FOX, JULLYSA WYNELL CORRINNE
Entity type:Individual
Prefix:
First Name:JULLYSA
Middle Name:WYNELL CORRINNE
Last Name:FOX
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 1:748 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2315
Mailing Address - Country:US
Mailing Address - Phone:360-200-5419
Mailing Address - Fax:
Practice Address - Street 1:1720 N HAMILTON ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-2474
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 175T00000X
WA61379883106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No175T00000XOther Service ProvidersPeer Specialist