Provider Demographics
NPI:1386280055
Name:PORT, JESSICA ANN (PSYD, LPC, CCTP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:PORT
Suffix:
Gender:F
Credentials:PSYD, LPC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 LITITZ PIKE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6501
Mailing Address - Country:US
Mailing Address - Phone:717-391-6808
Mailing Address - Fax:
Practice Address - Street 1:1831 LITITZ PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6501
Practice Address - Country:US
Practice Address - Phone:717-391-6808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-020167103TC0700X
PAPC010683101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health