Provider Demographics
NPI:1053872721
Name:HENDERSON, JESSICA D (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:C
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3944 NE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-1321
Mailing Address - Country:US
Mailing Address - Phone:919-280-9880
Mailing Address - Fax:
Practice Address - Street 1:444 W FORT ST FL 2
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4535
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL75521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical