Provider Demographics
NPI:1174075725
Name:VANCE, JESSICA NICOLE
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:NICOLE
Last Name:VANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 MACKEY PL
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2544
Mailing Address - Country:US
Mailing Address - Phone:318-220-8423
Mailing Address - Fax:318-220-8573
Practice Address - Street 1:2715 MACKEY PL
Practice Address - Street 2:SUITE 135
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2544
Practice Address - Country:US
Practice Address - Phone:318-220-8423
Practice Address - Fax:318-220-8573
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$Medicaid