Provider Demographics
NPI:1154565984
Name:TYE, JESSICA (EDD, MSW, LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TYE
Suffix:
Gender:F
Credentials:EDD, MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 12TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920-1391
Mailing Address - Country:US
Mailing Address - Phone:507-316-4674
Mailing Address - Fax:
Practice Address - Street 1:467 12TH ST NW
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:MN
Practice Address - Zip Code:55920-1391
Practice Address - Country:US
Practice Address - Phone:507-316-4674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN177071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical