Healthcare Provider Details

I. General information

NPI: 1255996807
Provider Name (Legal Business Name): JESSICA WELLS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA WARD

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 EAST ANDERSON LANE, SUITE 120
AUSTIN TX
78752
US

IV. Provider business mailing address

8705 SHOAL CREEK BLVD STE 108
AUSTIN TX
78757-6839
US

V. Phone/Fax

Practice location:
  • Phone: 512-961-5575
  • Fax:
Mailing address:
  • Phone: 512-200-4112
  • Fax: 512-287-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number58871
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: