Provider Demographics
NPI:1649010471
Name:CONWAY, JESSICA LYNN (LPC, MA)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LYNN
Last Name:CONWAY
Suffix:
Gender:F
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2506
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-2506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:73 CUCHARA AVE E
Practice Address - Street 2:
Practice Address - City:LA VETA
Practice Address - State:CO
Practice Address - Zip Code:81055-9783
Practice Address - Country:US
Practice Address - Phone:719-237-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0020536101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health