Provider Demographics
NPI:1396010286
Name:KULLBERG, JESSIE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:KULLBERG
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:PO BOX 1316
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-0088
Mailing Address - Country:US
Mailing Address - Phone:541-260-6098
Mailing Address - Fax:
Practice Address - Street 1:1944 SHERMAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-3478
Practice Address - Country:US
Practice Address - Phone:541-260-6098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL52711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical