Provider Demographics
NPI:1437756517
Name:DAVIS, JANESSA MARKQUISHA
Entity Type:Individual
Prefix:
First Name:JANESSA
Middle Name:MARKQUISHA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 BEDFORD AVE APT 13
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-3760
Mailing Address - Country:US
Mailing Address - Phone:531-541-3137
Mailing Address - Fax:
Practice Address - Street 1:500 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-0827
Practice Address - Country:US
Practice Address - Phone:712-256-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101631101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health