Provider Demographics
NPI:1205663036
Name:MIR, JESSE A (LCSW)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:A
Last Name:MIR
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 CORTHELL RD
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4875
Mailing Address - Country:US
Mailing Address - Phone:973-873-8432
Mailing Address - Fax:
Practice Address - Street 1:204 MCCOLLUM ST STE 201
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5127
Practice Address - Country:US
Practice Address - Phone:973-873-8432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC062612001041C0700X
WYLCSW-16251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical