Provider Demographics
NPI:1679708390
Name:ANDERSON, JESSICA LEA (MA LPC NCC)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LEA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA LPC NCC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25 KESSEL CT STE 105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:608-280-2700
Mailing Address - Fax:
Practice Address - Street 1:1320 MENDOTA ST STE 120
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-1060
Practice Address - Country:US
Practice Address - Phone:608-280-3106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
COLPC.0011615101YP2500X
WI5854-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679708390Medicaid