Provider Demographics
NPI:1447340161
Name:ROBERTSON, JESSICA ELLEN (MS, LMFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 GOVERNMENT ST STE A
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3937
Mailing Address - Country:US
Mailing Address - Phone:228-382-3107
Mailing Address - Fax:800-854-0906
Practice Address - Street 1:2130 GOVERNMENT ST STE A
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3937
Practice Address - Country:US
Practice Address - Phone:228-382-3107
Practice Address - Fax:800-854-0906
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0437106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid