Provider Demographics
NPI:1174004998
Name:SYVERSEN, JESSICA MARI
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARI
Last Name:SYVERSEN
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 1:418 N 1ST ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3216
Mailing Address - Country:US
Mailing Address - Phone:815-761-4500
Mailing Address - Fax:
Practice Address - Street 1:816 FEATHERSTONE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6300
Practice Address - Country:US
Practice Address - Phone:815-227-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150101900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker