Provider Demographics
NPI:1134563497
Name:STANLEY, JESSICA MARIE (LCDC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:STANLEY
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 BEAUMONT AVE
Mailing Address - Street 2:STE D-1
Mailing Address - City:LIBERTY
Mailing Address - State:TX
Mailing Address - Zip Code:77575-5126
Mailing Address - Country:US
Mailing Address - Phone:936-776-2979
Mailing Address - Fax:281-377-5870
Practice Address - Street 1:2800 BEAUMONT AVE
Practice Address - Street 2:STE. D-1
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-5126
Practice Address - Country:US
Practice Address - Phone:936-776-2979
Practice Address - Fax:281-377-5870
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11991101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)