Provider Demographics
NPI:1265992044
Name:LANDRAM, JESSICA (CSW-I)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LANDRAM
Suffix:
Gender:F
Credentials:CSW-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6575 W TROPICANA AVE APT 2097
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 E FLAMINGO RD STE D
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5190
Practice Address - Country:US
Practice Address - Phone:702-272-0987
Practice Address - Fax:702-823-1196
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIC-13031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical