Provider Demographics
NPI:1265294995
Name:HART, JESSICA RAE (PHD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:RAE
Last Name:HART
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RAE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4349 NETTLE DR SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5557
Mailing Address - Country:US
Mailing Address - Phone:940-249-6935
Mailing Address - Fax:
Practice Address - Street 1:1949 S STATE ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2818
Practice Address - Country:US
Practice Address - Phone:253-328-3507
Practice Address - Fax:253-761-7577
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3486103TF0200X
WAPY61170219103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic