Provider Demographics
NPI:1609354075
Name:SHEA, JESSICA (CSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 S BAYLY AVE APT A
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2574
Mailing Address - Country:US
Mailing Address - Phone:931-808-6271
Mailing Address - Fax:
Practice Address - Street 1:355 S BAYLY AVE APT A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2574
Practice Address - Country:US
Practice Address - Phone:931-808-6271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-29
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252858104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker