Provider Demographics
NPI:1760866271
Name:DAVIS, JESSICA (PSYD LP)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 LONG LAKE RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6428
Mailing Address - Country:US
Mailing Address - Phone:612-706-9630
Mailing Address - Fax:
Practice Address - Street 1:900 LONG LAKE RD
Practice Address - Street 2:SUITE 160
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6428
Practice Address - Country:US
Practice Address - Phone:612-706-9630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6049103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical