Provider Demographics
NPI:1053766980
Name:DAVIDSON, JESSICA (MA, LPC, ATR)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MA, LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14426 S OUTER 40 RD
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5711
Mailing Address - Country:US
Mailing Address - Phone:636-224-1300
Mailing Address - Fax:
Practice Address - Street 1:14426 S OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-5711
Practice Address - Country:US
Practice Address - Phone:636-224-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008027607101YP2500X
IL180008597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
13545669OtherCAQH