Provider Demographics
NPI:1841328580
Name:JESDALE, DEBORAH A (LICSW, LMHC)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:JESDALE
Suffix:
Gender:F
Credentials:LICSW, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-1236
Mailing Address - Country:US
Mailing Address - Phone:401-624-7473
Mailing Address - Fax:
Practice Address - Street 1:155 MAIN RD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-1236
Practice Address - Country:US
Practice Address - Phone:401-624-7473
Practice Address - Fax:401-683-2109
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW01065104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI26943OtherRI BLUE CROSS BLUE SHIELD
RI408941OtherBLUE CHIP COORDINATED HEA
RI1021420OtherBEACON HEALTH STRATEGIES
RI26943OtherRI BLUE CROSS BLUE SHIELD