Provider Demographics
NPI:1235536632
Name:BUSACK, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BUSACK
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 1:266 TIMBER HEARTH CT
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-9217
Mailing Address - Country:US
Mailing Address - Phone:740-403-9670
Mailing Address - Fax:
Practice Address - Street 1:621 MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-4615
Practice Address - Country:US
Practice Address - Phone:740-670-7076
Practice Address - Fax:740-670-7039
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20632256103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool