Provider Demographics
NPI:1053631143
Name:ANDERSON, JESSIE S
Entity Type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:S
Last Name:ANDERSON
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:PO BOX 21926
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33416-1926
Mailing Address - Country:US
Mailing Address - Phone:561-633-1986
Mailing Address - Fax:
Practice Address - Street 1:1320 W 10TH ST
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-6619
Practice Address - Country:US
Practice Address - Phone:561-633-1986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health