Provider Demographics
NPI:1346658465
Name:BACK, JESSICA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BACK
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 1:2804 FORUM BLVD
Mailing Address - Street 2:3A
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6322
Mailing Address - Country:US
Mailing Address - Phone:573-446-6290
Mailing Address - Fax:
Practice Address - Street 1:2804 FORUM BLVD
Practice Address - Street 2:3A
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6322
Practice Address - Country:US
Practice Address - Phone:573-446-6290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140128821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical