Provider Demographics
NPI:1003388745
Name:MAXWELL, JESSICA LOUISE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE
Last Name:MAXWELL
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 1:7922 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-4117
Mailing Address - Country:US
Mailing Address - Phone:214-763-0068
Mailing Address - Fax:
Practice Address - Street 1:10001 LAKE FOREST BLVD STE 404
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-6201
Practice Address - Country:US
Practice Address - Phone:504-821-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6427101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health