Provider Demographics
NPI:1871133132
Name:THORNBURG, JESSICA E
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:THORNBURG
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 1:6575 W 185TH TER
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:KS
Mailing Address - Zip Code:66085-8917
Mailing Address - Country:US
Mailing Address - Phone:267-679-9690
Mailing Address - Fax:
Practice Address - Street 1:6575 W 185TH TER
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:KS
Practice Address - Zip Code:66085-8917
Practice Address - Country:US
Practice Address - Phone:267-679-9690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS50531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical