Provider Demographics
NPI:1982795290
Name:STOCKMAN, JESSICA IRENE (LPC)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:IRENE
Last Name:STOCKMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7685 VERANDA BLVD
Mailing Address - Street 2:#2
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-3964
Mailing Address - Country:US
Mailing Address - Phone:801-473-1051
Mailing Address - Fax:
Practice Address - Street 1:7075 GOLDEN OAKS LOOP W
Practice Address - Street 2:STE. 3
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9010
Practice Address - Country:US
Practice Address - Phone:662-349-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1185101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional