Provider Demographics
NPI:1720437569
Name:STUNSON, JESSICA L (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:STUNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 SAINT PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-6586
Mailing Address - Country:US
Mailing Address - Phone:270-799-7247
Mailing Address - Fax:
Practice Address - Street 1:1212 ASHLEY CIR STE 3
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5821
Practice Address - Country:US
Practice Address - Phone:270-864-6872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2538771041C0700X
KY7708104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid