Provider Demographics
NPI:1104532605
Name:SWAN, JESSICA L (MCJ, LSATP, MAC, CAS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:SWAN
Suffix:
Gender:F
Credentials:MCJ, LSATP, MAC, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 SHADY BLUFF PT
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2236
Mailing Address - Country:US
Mailing Address - Phone:757-231-3345
Mailing Address - Fax:
Practice Address - Street 1:106 SHADY BLUFF PT
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2236
Practice Address - Country:US
Practice Address - Phone:175-723-1334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0020871101YA0400X
VA0718000496101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)