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General NPI Number Information
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NPI Number | 1659911436
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Entity Type | Individual
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Provider Name | JESSICA MCGUIRE
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Gender | Female
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Dates
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Enumeration Date | 01/09/2020
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 1305 PINE LAKE RD STE 2B
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City | LA PORTE
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State | IN
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Zip | 46350-2039
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Country | US
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Telephone | 219-809-2345
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Fax |
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Provider Business Mailing Address
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Address Line | 512 ANDREW AVE UNIT 102
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City | LA PORTE
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State | IN
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Zip | 46350-4633
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Country | US
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Telephone | 219-809-2345
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 35002431A
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License Number State | IN
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