MEDICARE: ASHLEY JESSICA DIEDRICH LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YP2500X	Professional Counselor	6314	OK

General Provider Information

NPI Number	:	1124387329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY JESSICA DIEDRICH LPC

Provider Business Mailing Address
First Line	:	118 N 2ND ST STE 200
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-2894
Country	:	US
Telephone Number	:	636-224-1210
Fax Number	:	636-946-0991

Provider Business Practice Location Address
First Line	:	609 E HARTFORD AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2006
Country	:	US
Telephone Number	:	580-765-0030
Fax Number	:	580-765-0073

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2012
Last Update Date	:	03/29/2019

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