Provider Demographics
NPI:1790285633
Name:TALLEY, JESSICA NICOLE (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:TALLEY
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11909 ECHO POINT PL
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-5335
Mailing Address - Country:US
Mailing Address - Phone:240-405-4630
Mailing Address - Fax:
Practice Address - Street 1:11909 ECHO POINT PL
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-5335
Practice Address - Country:US
Practice Address - Phone:240-405-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23164104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker