Healthcare Provider Details

I. General information

NPI: 1851112965
Provider Name (Legal Business Name): JESSICA LEE EDGE LMHC, CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3949 CORRALES RD STE 205
CORRALES NM
87048-9348
US

IV. Provider business mailing address

PO BOX 521
CEDAR CREST NM
87008-0521
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-0439
  • Fax:
Mailing address:
  • Phone: 720-471-9752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0650
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: