Healthcare Provider Details

I. General information

NPI: 1598501868
Provider Name (Legal Business Name): JESSICA LYN CICOGNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W ANTRIM DR
GREENVILLE SC
29607-2329
US

IV. Provider business mailing address

221 FAIRFOREST WAY APT 17101
GREENVILLE SC
29607-4677
US

V. Phone/Fax

Practice location:
  • Phone: 864-351-2481
  • Fax:
Mailing address:
  • Phone: 740-359-4435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9088
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: