Provider Demographics
NPI:1962170860
Name:LOVE, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W 1ST ST STE 270
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1770
Mailing Address - Country:US
Mailing Address - Phone:715-246-4840
Mailing Address - Fax:715-254-9495
Practice Address - Street 1:150 W 1ST ST STE 270
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1770
Practice Address - Country:US
Practice Address - Phone:715-246-4840
Practice Address - Fax:715-254-9495
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5081-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional