Provider Demographics
NPI:1568445484
Name:PICKENS, JESSICA JOHANNA (MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOHANNA
Last Name:PICKENS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11416 N 200TH ST
Mailing Address - Street 2:
Mailing Address - City:WHEELER
Mailing Address - State:IL
Mailing Address - Zip Code:62479-2447
Mailing Address - Country:US
Mailing Address - Phone:217-925-5868
Mailing Address - Fax:
Practice Address - Street 1:1200 N 4TH ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-3032
Practice Address - Country:US
Practice Address - Phone:217-347-7179
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor