=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497290738
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JESSICA CARR, LMHC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2016
-----------------------------------------------------
Last Update Date | 12/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9200 BONITA BEACH RD SE SUITE 212
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-4280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-895-8146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9200 BONITA BEACH RD SE SUITE 212
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-4280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-895-8146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA ROBERTSON CARR
-----------------------------------------------------
Credential | M.A., LMHC
-----------------------------------------------------
Telephone | 239-895-8146
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH11294
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------