Provider Demographics
NPI:1922309541
Name:GUPTA, JESSICA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WALNUT BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2086
Mailing Address - Country:US
Mailing Address - Phone:248-766-0818
Mailing Address - Fax:248-650-3225
Practice Address - Street 1:115 WALNUT BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-2086
Practice Address - Country:US
Practice Address - Phone:248-766-0818
Practice Address - Fax:248-650-3225
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.10003501041C0700X
MI68010932671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical