Provider Demographics
NPI:1124253307
Name:WALLIS, JONATHAN MARC (LCSW)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARC
Last Name:WALLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:J.
Other - Middle Name:MARC
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1610 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3014
Mailing Address - Country:US
Mailing Address - Phone:415-820-9609
Mailing Address - Fax:
Practice Address - Street 1:1610 SCOTT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3014
Practice Address - Country:US
Practice Address - Phone:415-820-9609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X
CALCS198581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst