Provider Demographics
NPI:1639474554
Name:CONANT, JESSICA LYNN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:CONANT
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 1:450 GOLDEN POND RD
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-9679
Mailing Address - Country:US
Mailing Address - Phone:401-862-7443
Mailing Address - Fax:
Practice Address - Street 1:450 GOLDEN POND RD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-9679
Practice Address - Country:US
Practice Address - Phone:401-862-7443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA119621041C0700X
390200000X
MA1179621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program