Provider Demographics
NPI:1114560117
Name:NISSEN, JESSICA RENEE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:NISSEN
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 1:1521 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2957
Mailing Address - Country:US
Mailing Address - Phone:573-210-8338
Mailing Address - Fax:
Practice Address - Street 1:2845 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5015
Practice Address - Country:US
Practice Address - Phone:573-803-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190199231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical