Provider Demographics
NPI:1417092214
Name:CONWAY, JESSICA ELLEN (MA, MFT)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ELLEN
Last Name:CONWAY
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 LANSING DR SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-3928
Mailing Address - Country:US
Mailing Address - Phone:703-899-2983
Mailing Address - Fax:
Practice Address - Street 1:1409 GRANDIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2317
Practice Address - Country:US
Practice Address - Phone:703-899-2983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46463106H00000X
VA0717001384106H00000X
VA0171001384101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist