Provider Demographics
NPI:1760027171
Name:MAGERS, JESSICA LYN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:MAGERS
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 1:817 MARALYN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-2829
Mailing Address - Country:US
Mailing Address - Phone:386-314-7207
Mailing Address - Fax:
Practice Address - Street 1:136 JULIA STREET
Practice Address - Street 2:UNIT 100
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168
Practice Address - Country:US
Practice Address - Phone:386-423-9161
Practice Address - Fax:386-423-3094
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-08
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17392101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH17392OtherSTATE LICENSE