Provider Demographics
NPI:1144765116
Name:PETERSON, JESSICA CARNESI (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:CARNESI
Last Name:PETERSON
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 1:6300 WEST LOOP S
Mailing Address - Street 2:SUITE 330
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-2900
Mailing Address - Country:US
Mailing Address - Phone:832-703-2572
Mailing Address - Fax:
Practice Address - Street 1:6300 WEST LOOP S
Practice Address - Street 2:SUITE 330
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2900
Practice Address - Country:US
Practice Address - Phone:832-703-2572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX423431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical