Provider Demographics
NPI:1659911436
Name:MCGUIRE, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCGUIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 ANDREW AVE UNIT 102
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-4633
Mailing Address - Country:US
Mailing Address - Phone:219-809-2345
Mailing Address - Fax:
Practice Address - Street 1:1305 PINE LAKE RD STE 2B
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2039
Practice Address - Country:US
Practice Address - Phone:219-809-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35002431A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist