Provider Demographics
NPI:1780158931
Name:JARVIS, ELISSA LEA (PSYD, LCP)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:LEA
Last Name:JARVIS
Suffix:
Gender:F
Credentials:PSYD, LCP
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:LEA
Other - Last Name:BRAUCHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:318 DARBY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23663-1306
Mailing Address - Country:US
Mailing Address - Phone:757-450-4201
Mailing Address - Fax:
Practice Address - Street 1:2010 OLD GREENBRIER RD STE J
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2619
Practice Address - Country:US
Practice Address - Phone:757-493-2912
Practice Address - Fax:866-730-6583
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006131103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical