Healthcare Provider Details

I. General information

NPI: 1376803619
Provider Name (Legal Business Name): JESSICA ASHLEY SERGIO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 5TH ST
FULTON MO
65251-1753
US

IV. Provider business mailing address

600 E 5TH ST
FULTON MO
65251-1753
US

V. Phone/Fax

Practice location:
  • Phone: 573-592-2628
  • Fax:
Mailing address:
  • Phone: 573-592-2628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2010036635
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: