Healthcare Provider Details

I. General information

NPI: 1568830750
Provider Name (Legal Business Name): JESSICA LYNN MYERS LPCC-S, LICDC-CS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 KETTERING BLVD
MORAINE OH
45439-1983
US

IV. Provider business mailing address

2206 SHROYER RD
OAKWOOD OH
45419-2623
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-8300
  • Fax:
Mailing address:
  • Phone: 937-367-7399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161309
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1800725-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: