Provider Demographics
NPI:1588058994
Name:EVANS, JESSICA DAWN (LPCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD. BLDG. B
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373
Practice Address - Country:US
Practice Address - Phone:937-440-7626
Practice Address - Fax:937-440-7702
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900294101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0240332Medicaid