Provider Demographics
NPI:1235687716
Name:NOAH, JESSICA LYNN (MFT-IT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:NOAH
Suffix:
Gender:F
Credentials:MFT-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 8TH ST. SO., STE 101
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494
Mailing Address - Country:US
Mailing Address - Phone:715-423-2030
Mailing Address - Fax:715-423-2032
Practice Address - Street 1:3930 8TH ST. SO., STE 101
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494
Practice Address - Country:US
Practice Address - Phone:715-423-2030
Practice Address - Fax:715-423-2032
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI563-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist