Provider Demographics
NPI:1720670243
Name:STULTS, JESSICA (LICSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STULTS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3727
Mailing Address - Country:US
Mailing Address - Phone:401-301-3352
Mailing Address - Fax:
Practice Address - Street 1:386 SMITH ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-3727
Practice Address - Country:US
Practice Address - Phone:401-861-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW032301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical