Provider Demographics
NPI:1275061152
Name:ERICKSON, JESSICA ROSE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:ERICKSON
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 1:5509 PARKVIEW HILLS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-6711
Mailing Address - Country:US
Mailing Address - Phone:817-332-6348
Mailing Address - Fax:817-332-6489
Practice Address - Street 1:8101 BOAT CLUB RD STE 305
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3635
Practice Address - Country:US
Practice Address - Phone:817-203-4479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74195101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional