Provider Demographics
NPI:1972119923
Name:QUEEN, JESSICA JOYCE (LGSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOYCE
Last Name:QUEEN
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8674 BLACK OAK RD
Mailing Address - Street 2:
Mailing Address - City:FRAZIERS BOTTOM
Mailing Address - State:WV
Mailing Address - Zip Code:25082-8009
Mailing Address - Country:US
Mailing Address - Phone:304-812-6966
Mailing Address - Fax:
Practice Address - Street 1:222 MAIN ST W
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271-1432
Practice Address - Country:US
Practice Address - Phone:740-416-0797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WV104100000X
WVBP009459351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVBP00945935OtherWV BOARD OF SOCIAL WORK