Provider Demographics
NPI:1457693194
Name:WEISEL, JESSE ROBERTA SMITH
Entity type:Individual
Prefix:MS
First Name:JESSE
Middle Name:ROBERTA SMITH
Last Name:WEISEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:ROBERTA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC, LMHC, BC-DMT
Mailing Address - Street 1:PO BOX 560473
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-0473
Mailing Address - Country:US
Mailing Address - Phone:678-622-6844
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 560473
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32956-0473
Practice Address - Country:US
Practice Address - Phone:678-622-6844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005544101YP2500X
FLMH20047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional