Provider Demographics
NPI:1124749213
Name:VAN LINGE, JESSICA (LICDC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:VAN LINGE
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-8956
Mailing Address - Country:US
Mailing Address - Phone:740-500-1391
Mailing Address - Fax:
Practice Address - Street 1:2065 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-8956
Practice Address - Country:US
Practice Address - Phone:740-500-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1124749213Medicaid