Provider Demographics
NPI:1669715173
Name:NORMAN, JESSICA MARIE (MS, LMFT, CADC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:NORMAN
Suffix:
Gender:F
Credentials:MS, LMFT, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-7631
Mailing Address - Country:US
Mailing Address - Phone:815-387-2453
Mailing Address - Fax:815-387-7997
Practice Address - Street 1:3815 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-7631
Practice Address - Country:US
Practice Address - Phone:815-387-2453
Practice Address - Fax:815-387-7997
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI321-228101YM0800X
WI16793-130101YM0800X
IL166001087106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health