Provider Demographics
NPI:1285122002
Name:BLUM, JESSICA ASHLEY (LPC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ASHLEY
Last Name:BLUM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:ASHLEY
Other - Last Name:FRANKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:820 PARK DR
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-1566
Mailing Address - Country:US
Mailing Address - Phone:573-883-7407
Mailing Address - Fax:573-883-7537
Practice Address - Street 1:820 PARK DR
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-1566
Practice Address - Country:US
Practice Address - Phone:573-883-7407
Practice Address - Fax:573-883-7537
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018012458101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490053268Medicaid