Provider Demographics
NPI:1053047019
Name:CUSTER, JESSICA DODD
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DODD
Last Name:CUSTER
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 1:8309 MISTY LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34241-8502
Mailing Address - Country:US
Mailing Address - Phone:208-841-0490
Mailing Address - Fax:
Practice Address - Street 1:4071 BEE RIDGE RD STE 204
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2542
Practice Address - Country:US
Practice Address - Phone:208-841-0490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health