Provider Demographics
NPI:1265694947
Name:DEAN, JESSICA KATHRYN (LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KATHRYN
Last Name:DEAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 S. 79TH CIRCLE
Mailing Address - Street 2:
Mailing Address - City:RALSTON
Mailing Address - State:NE
Mailing Address - Zip Code:68127
Mailing Address - Country:US
Mailing Address - Phone:402-212-9181
Mailing Address - Fax:
Practice Address - Street 1:201 N BACKUS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:402-212-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
NE1733101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner