MEDICARE: JESSICA MARY SWEENEY LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	22788	MN
2	1041C0700X	Clinical Social Worker	22788	MN

General Provider Information

NPI Number	:	1184074940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MARY SWEENEY LICSW

Provider Business Mailing Address
First Line	:	324 W SUPERIOR ST STE 911
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55802-1717
Country	:	US
Telephone Number	:	218-270-5055
Fax Number	:

Provider Business Practice Location Address
First Line	:	324 W SUPERIOR ST STE 911
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55802-1717
Country	:	US
Telephone Number	:	218-270-5055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2016
Last Update Date	:	03/25/2020

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