Provider Demographics
NPI:1326270042
Name:SOUKUP, JESSICA L (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:SOUKUP
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 1:1064 RIDGEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-4372
Mailing Address - Country:US
Mailing Address - Phone:775-720-8676
Mailing Address - Fax:775-418-7636
Practice Address - Street 1:407 N WALSH ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-4268
Practice Address - Country:US
Practice Address - Phone:775-720-8676
Practice Address - Fax:775-418-7636
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4690-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV4960-COtherSTATE LICENSE