Provider Demographics
NPI:1952303612
Name:PENSON-HEYDER, JESSICA (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JESSICA
Middle Name:
Last Name:PENSON-HEYDER
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:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:POWELLS POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27966-0347
Mailing Address - Country:US
Mailing Address - Phone:252-491-8128
Mailing Address - Fax:252-491-2720
Practice Address - Street 1:206 NEWBERN ROAD
Practice Address - Street 2:
Practice Address - City:JARVISBURG
Practice Address - State:NC
Practice Address - Zip Code:27947
Practice Address - Country:US
Practice Address - Phone:252-491-8128
Practice Address - Fax:252-491-2720
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0000021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY66782OtherBC/BS
NC6002015Medicaid
NC6002015Medicaid