Provider Demographics
NPI:1740585025
Name:JESSEN, JOHN BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRUCE
Last Name:JESSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 S BELLGROVE LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-6185
Mailing Address - Country:US
Mailing Address - Phone:509-389-3713
Mailing Address - Fax:
Practice Address - Street 1:4107 S BELLGROVE LN
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-6185
Practice Address - Country:US
Practice Address - Phone:509-389-3713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60196969103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical