Provider Demographics
NPI:1578070124
Name:SANSOUCIE, JESSICA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SANSOUCIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MATCZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:207 MCKEAN CT
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1081
Mailing Address - Country:US
Mailing Address - Phone:609-678-8007
Mailing Address - Fax:
Practice Address - Street 1:218 FAST ICE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-6167
Practice Address - Country:US
Practice Address - Phone:989-631-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102083104100000X
MI68011065001041C0700X
PACW0212621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker