Healthcare Provider Details

I. General information

NPI: 1194586099
Provider Name (Legal Business Name): JESSICA DEARDORFF LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 S LEMON AVE STE 9892
WALNUT CA
91789-2706
US

IV. Provider business mailing address

113 MUSTANG LN
BERKELEY SPRINGS WV
25411-6955
US

V. Phone/Fax

Practice location:
  • Phone: 415-645-5759
  • Fax:
Mailing address:
  • Phone: 443-472-3417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00945771
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: