Provider Demographics
NPI:1386804862
Name:CONLEY, JESSICA SAMFORD (LPC - MHSP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SAMFORD
Last Name:CONLEY
Suffix:
Gender:F
Credentials:LPC - MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3759
Mailing Address - Country:US
Mailing Address - Phone:615-415-2212
Mailing Address - Fax:866-867-4298
Practice Address - Street 1:713 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2150
Practice Address - Country:US
Practice Address - Phone:615-415-2212
Practice Address - Fax:866-867-4298
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2173OtherLPC- MHSP LIC #
TN12069176OtherCAQH