Provider Demographics
NPI:1124668181
Name:EHMANN, JEROME S (LPC, LISAC)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:S
Last Name:EHMANN
Suffix:
Gender:M
Credentials:LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 E MISSION LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-5324
Mailing Address - Country:US
Mailing Address - Phone:719-338-8535
Mailing Address - Fax:
Practice Address - Street 1:7600 N 15TH ST STE 36
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4327
Practice Address - Country:US
Practice Address - Phone:602-321-0105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15151101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)