Healthcare Provider Details

I. General information

NPI: 1528307386
Provider Name (Legal Business Name): JESSICA FORDE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CENTER 100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

NAVAL MEDICAL CENTER 100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2538
US

V. Phone/Fax

Practice location:
  • Phone: 910-449-1104
  • Fax:
Mailing address:
  • Phone: 910-449-1104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number5599
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5599
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: