=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851112965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA LEE EDGE LMHC, CHW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2024
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3949 CORRALES RD STE 205
-----------------------------------------------------
City | CORRALES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87048-9348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-385-0439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 521
-----------------------------------------------------
City | CEDAR CREST
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87008-0521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-471-9752
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CTB-2024-0650
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------