Provider Demographics
NPI:1104329598
Name:CARROLL, JESSICA (LPCA, NCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LPCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 SMUGGLERS NOTCH DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4394
Mailing Address - Country:US
Mailing Address - Phone:606-272-4902
Mailing Address - Fax:
Practice Address - Street 1:114 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-1986
Practice Address - Country:US
Practice Address - Phone:606-404-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY270481101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid