Provider Demographics
NPI:1689173288
Name:FREEMAN, JESSICA ELLEN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 CONTINENTAL ST
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4806
Mailing Address - Country:US
Mailing Address - Phone:307-922-6644
Mailing Address - Fax:
Practice Address - Street 1:922 CONTINENTAL ST
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4806
Practice Address - Country:US
Practice Address - Phone:307-922-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0-23-14484106E00000X
WYRBT-18-49211106S00000X
251B00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty