Provider Demographics
NPI:1407313596
Name:SWANSON, JESSICA RENEE (PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 S SHARON AMITY RD STE 250
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2850
Mailing Address - Country:US
Mailing Address - Phone:704-507-0387
Mailing Address - Fax:980-498-6700
Practice Address - Street 1:447 S SHARON AMITY RD STE 250
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2850
Practice Address - Country:US
Practice Address - Phone:704-507-0387
Practice Address - Fax:980-498-6700
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist