Healthcare Provider Details

I. General information

NPI: 1932592649
Provider Name (Legal Business Name): JESSICA CANTRELL MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA THOMAS

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 N TRUMAN BLVD STE H
CRYSTAL CITY MO
63019-1344
US

IV. Provider business mailing address

358 MEADOW WOOD DR
FESTUS MO
63028-2041
US

V. Phone/Fax

Practice location:
  • Phone: 636-465-9006
  • Fax:
Mailing address:
  • Phone: 636-206-4351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2015013402
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: