Provider Demographics
NPI:1215289376
Name:SMITH, JESSICA SKY (LICSW)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:SKY
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:SKY
Other - Last Name:NIESEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:301 N. BROAD ST.
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-951-3874
Mailing Address - Fax:
Practice Address - Street 1:103 N BROAD ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3519
Practice Address - Country:US
Practice Address - Phone:507-345-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN205931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical