Provider Demographics
NPI:1477338424
Name:DEAN, JESSICA TAYLOR
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:TAYLOR
Last Name:DEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:TAYLOR
Other - Last Name:RAYBORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3986 ECLIPSE AVE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-2369
Mailing Address - Country:US
Mailing Address - Phone:803-554-2565
Mailing Address - Fax:
Practice Address - Street 1:1209 CULBRETH DR STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-8318
Practice Address - Country:US
Practice Address - Phone:910-800-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10163A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist