Provider Demographics
NPI:1962959098
Name:WOODY, JESSICA (MA, LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WOODY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1845
Mailing Address - Country:US
Mailing Address - Phone:937-681-9164
Mailing Address - Fax:
Practice Address - Street 1:3011KETTERING BLVD
Practice Address - Street 2:SUITE 311
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439
Practice Address - Country:US
Practice Address - Phone:937-424-0210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC 1300245101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health