Healthcare Provider Details

I. General information

NPI: 1912334822
Provider Name (Legal Business Name): JESSICA JAYNE STORY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12165 STATE HIGHWAY 14 N STE B7
CEDAR CREST NM
87008-9538
US

IV. Provider business mailing address

78 POMEROY TER
NORTHAMPTON MA
01060-3378
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-7771
  • Fax:
Mailing address:
  • Phone: 413-585-1310
  • Fax: 413-586-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-11338
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: