Provider Demographics
NPI:1508357336
Name:PETTIGREW, JESSICA SHANNON (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHANNON
Last Name:PETTIGREW
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 1:1155 KELLY JOHNSON BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3957
Mailing Address - Country:US
Mailing Address - Phone:970-316-2161
Mailing Address - Fax:
Practice Address - Street 1:1155 KELLY JOHNSON BLVD STE 111
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3957
Practice Address - Country:US
Practice Address - Phone:970-316-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2530331041C0700X
CO099294441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical