Provider Demographics
NPI:1881906402
Name:SULLIVAN, JESSICA R (LICSW)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:R
Other - Last Name:BURKOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 MYRON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-1598
Mailing Address - Country:US
Mailing Address - Phone:413-592-1980
Mailing Address - Fax:413-439-0100
Practice Address - Street 1:103 MYRON ST
Practice Address - Street 2:SUITE A
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1598
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0100
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1196391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical