Healthcare Provider Details

I. General information

NPI: 1417092214
Provider Name (Legal Business Name): JESSICA ELLEN CONWAY MA, MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 GRANDIN RD SW
ROANOKE VA
24015-2317
US

IV. Provider business mailing address

2713 LANSING DR SW
ROANOKE VA
24015-3928
US

V. Phone/Fax

Practice location:
  • Phone: 703-899-2983
  • Fax:
Mailing address:
  • Phone: 703-899-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0171001384
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number46463
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001384
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: