Provider Demographics
NPI:1396960100
Name:BABCOCK, JESSE HUGH III (LICENSED CLINICAL SO)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:HUGH
Last Name:BABCOCK
Suffix:III
Gender:M
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 SE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1380
Mailing Address - Country:US
Mailing Address - Phone:239-218-3286
Mailing Address - Fax:
Practice Address - Street 1:1903 SE 2ND ST
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1380
Practice Address - Country:US
Practice Address - Phone:239-218-3286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC10384104100000X
FL97681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431745099Medicaid