Provider Demographics
NPI:1336448984
Name:SULLIVAN, JESSICA MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6497 PARKLAND DR STE A
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-4097
Mailing Address - Country:US
Mailing Address - Phone:941-681-8260
Mailing Address - Fax:941-251-8230
Practice Address - Street 1:6497 PARKLAND DR STE A
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-4097
Practice Address - Country:US
Practice Address - Phone:941-681-8260
Practice Address - Fax:941-251-8230
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLPY10510103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health