Provider Demographics
NPI:1922551316
Name:JESSE, MELANIE (LCSW)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:JESSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:IL
Mailing Address - Zip Code:62558-9619
Mailing Address - Country:US
Mailing Address - Phone:217-883-0708
Mailing Address - Fax:
Practice Address - Street 1:1215 4TH ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:IL
Practice Address - Zip Code:62558-9619
Practice Address - Country:US
Practice Address - Phone:217-883-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490181251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical