Healthcare Provider Details

I. General information

NPI: 1194586099
Provider Name (Legal Business Name): JESSICA DEARDORFF LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 8TH ST
MARLINTON WV
24954-1027
US

IV. Provider business mailing address

113 MUSTANG LN
BERKELEY SPRINGS WV
25411-6955
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-7088
  • Fax: 833-419-0181
Mailing address:
  • Phone: 443-472-3417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904020463
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00945771
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: