Provider Demographics
NPI:1083046593
Name:STALLARD, JESSICA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STALLARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 BYPASS RD
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179
Mailing Address - Country:US
Mailing Address - Phone:540-767-2667
Mailing Address - Fax:540-767-2669
Practice Address - Street 1:1120 BYPASS RD
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179
Practice Address - Country:US
Practice Address - Phone:540-767-2667
Practice Address - Fax:540-767-2669
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040082991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437137734Medicaid