Provider Demographics
NPI:1730703950
Name:VICIC, JESSICA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:VICIC
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 PARK RD STE 102C
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3650
Mailing Address - Country:US
Mailing Address - Phone:704-433-5267
Mailing Address - Fax:
Practice Address - Street 1:6849 FAIRVIEW RD STE 702
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3393
Practice Address - Country:US
Practice Address - Phone:980-308-4500
Practice Address - Fax:980-458-6037
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NCC0155751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician