Provider Demographics
NPI:1093328965
Name:REVELL, JESSICA (LSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:REVELL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-2338
Mailing Address - Country:US
Mailing Address - Phone:814-490-4899
Mailing Address - Fax:
Practice Address - Street 1:1330 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-1402
Practice Address - Country:US
Practice Address - Phone:814-459-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0234111041C0700X
PASW137073104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical