Provider Demographics
NPI:1386029304
Name:TAZELAAR, JESSICA NICOLE (CSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:TAZELAAR
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 4TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-1467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 TYLER LN
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-8827
Practice Address - Country:US
Practice Address - Phone:606-723-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7346104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid