Provider Demographics
NPI:1528653433
Name:STEVENSON, JESSICA (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 OLD COLONY LN
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2410
Mailing Address - Country:US
Mailing Address - Phone:860-490-2262
Mailing Address - Fax:
Practice Address - Street 1:154 WEST ST STE 3D
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-4400
Practice Address - Country:US
Practice Address - Phone:860-893-5628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003868101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional