Provider Demographics
NPI:1215289202
Name:GENTRY, JESSICA LEA (LPC, LMHC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEA
Last Name:GENTRY
Suffix:
Gender:F
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 S DESOTO ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-2103
Mailing Address - Country:US
Mailing Address - Phone:512-461-3834
Mailing Address - Fax:
Practice Address - Street 1:7111 S DESOTO ST STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33616-2103
Practice Address - Country:US
Practice Address - Phone:512-461-3834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69489101YP2500X
FL21122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional