Healthcare Provider Details

I. General information

NPI: 1013836394
Provider Name (Legal Business Name): JESSICA ANN KIDWELL-SABOSKI LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 WOODWARD ST
LA PORTE IN
46350-3758
US

IV. Provider business mailing address

212 WOODWARD ST
LA PORTE IN
46350-3758
US

V. Phone/Fax

Practice location:
  • Phone: 219-363-5781
  • Fax:
Mailing address:
  • Phone: 219-363-5781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number99137508A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: