Provider Demographics
NPI:1124519756
Name:GAMBOA, JAI'LYSA (MHP, LMHC, CMHS)
Entity type:Individual
Prefix:
First Name:JAI'LYSA
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:MHP, LMHC, CMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 W RIVERSIDE AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-1011
Mailing Address - Country:US
Mailing Address - Phone:509-350-2909
Mailing Address - Fax:
Practice Address - Street 1:421 W RIVERSIDE AVE STE 312
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-5070
Practice Address - Country:US
Practice Address - Phone:509-350-2909
Practice Address - Fax:509-463-7205
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61133455101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health