Provider Demographics
NPI:1275919144
Name:FORD, JESSICA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FORD
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 1:3726 RIDGEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-4654
Mailing Address - Country:US
Mailing Address - Phone:262-744-4090
Mailing Address - Fax:
Practice Address - Street 1:8825 SOUTH HOWELL AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:OAK CREEK
Practice Address - State:WISCONSIN
Practice Address - Zip Code:53154
Practice Address - Country:UM
Practice Address - Phone:262-744-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8338-1231041C0700X
249309106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist