Provider Demographics
NPI:1689838583
Name:KNUDSEN, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:KNUDSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:MCDEAVITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8535 TOM SLICK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3367
Mailing Address - Country:US
Mailing Address - Phone:210-616-0300
Mailing Address - Fax:
Practice Address - Street 1:8535 TOM SLICK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3367
Practice Address - Country:US
Practice Address - Phone:210-616-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2874915Medicare PIN