Healthcare Provider Details

I. General information

NPI: 1801442454
Provider Name (Legal Business Name): JESSICA MARIE PATRICK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 SE 163RD STREET ROAD
SUMMERFIELD FL
34491
US

IV. Provider business mailing address

2805 SE 163RD STREET ROAD
SUMMERFIELD FL
34491
US

V. Phone/Fax

Practice location:
  • Phone: 386-365-0523
  • Fax:
Mailing address:
  • Phone: 386-365-0523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW23244
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: