Healthcare Provider Details

I. General information

NPI: 1104332907
Provider Name (Legal Business Name): JESSICA HANSEN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2017
Last Update Date: 12/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 MEADOWSWEET LN
VICKSBURG MI
49097-9487
US

IV. Provider business mailing address

1114 MEADOWSWEET LN
VICKSBURG MI
49097-9487
US

V. Phone/Fax

Practice location:
  • Phone: 269-760-6650
  • Fax:
Mailing address:
  • Phone: 269-760-6650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011082
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006406
License Number StateMI

VIII. Authorized Official

Name: JESSICA HANSEN-VANABEL
Title or Position: OWNER
Credential: LPC, LMFT
Phone: 269-760-6650