Provider Demographics
NPI:1194586099
Name:DEARDORFF, JESSICA (LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DEARDORFF
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 MUSTANG LN
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-6955
Mailing Address - Country:US
Mailing Address - Phone:443-472-3417
Mailing Address - Fax:
Practice Address - Street 1:340 S LEMON AVE STE 9892
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2706
Practice Address - Country:US
Practice Address - Phone:415-645-5759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009457711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical