Provider Demographics
NPI:1194333732
Name:WALLER, JESSICA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:WALLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 CLAPHAM LN
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423-9235
Mailing Address - Country:US
Mailing Address - Phone:775-720-1802
Mailing Address - Fax:
Practice Address - Street 1:1665 OLD HOT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-0782
Practice Address - Country:US
Practice Address - Phone:775-687-0874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8857-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical