Provider Demographics
NPI:1730656547
Name:SWANSON, JESSICA LYNN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:SWANSON
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 1:513 WILKES LN
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-6218
Mailing Address - Country:US
Mailing Address - Phone:813-777-6798
Mailing Address - Fax:831-901-3774
Practice Address - Street 1:513 WILKES LN
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-6218
Practice Address - Country:US
Practice Address - Phone:813-777-6798
Practice Address - Fax:831-901-3774
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-37941103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty