Provider Demographics
NPI:1811488471
Name:STREETER, JESSICA DAWN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:STREETER
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 1:16565 118TH AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-8843
Mailing Address - Country:US
Mailing Address - Phone:515-473-4888
Mailing Address - Fax:
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1597
Practice Address - Country:US
Practice Address - Phone:515-282-5752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090758104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker