MEDICARE: JESSICA SPENCE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	Q1-0001090	DE

General Provider Information

NPI Number	:	1265711030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA SPENCE LCSW

Provider Business Mailing Address
First Line	:	240 N JAMES ST
Second Line	:	SUITE 200
City	:	NEWPORT
State	:	DE
Zip	:	19804-3169
Country	:	US
Telephone Number	:	302-633-0301
Fax Number	:	302-633-0331

Provider Business Practice Location Address
First Line	:	190 SALEM CHURCH RD
Second Line	:
City	:	NEWARK
State	:	DE
Zip	:	19713-2938
Country	:	US
Telephone Number	:	302-454-5421
Fax Number	:	302-368-1421

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	10/03/2013

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