Provider Demographics
NPI:1326060757
Name:SPRAGUE, JESSIE LEE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:LEE
Last Name:SPRAGUE
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 1:202 N BARRY ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-2723
Mailing Address - Country:US
Mailing Address - Phone:716-373-0139
Mailing Address - Fax:585-593-7071
Practice Address - Street 1:4220 BOLIVAR RD
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-9332
Practice Address - Country:US
Practice Address - Phone:585-593-6300
Practice Address - Fax:585-593-7071
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055822-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000590264001OtherBC/BS OF WNY
NY00740423Medicaid
NYBB4455Medicare ID - Type Unspecified
NY00740423Medicaid