Provider Demographics
NPI:1013740422
Name:SALLE, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 AMBER CREST CT
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29365-9581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 SAINT MARK RD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-5233
Practice Address - Country:US
Practice Address - Phone:864-735-7231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7687106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist