Provider Demographics
NPI:1992806079
Name:ANTONIO, JESSICA (MA, LPC, NCC)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36-4 MOUNT PINE TER
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19606-3908
Mailing Address - Country:US
Mailing Address - Phone:484-431-4073
Mailing Address - Fax:
Practice Address - Street 1:2091 E HIGH ST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-3211
Practice Address - Country:US
Practice Address - Phone:610-970-5234
Practice Address - Fax:610-970-0945
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004122101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional