Provider Demographics
NPI:1053836437
Name:EDGE, JEREMY R (LPC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:R
Last Name:EDGE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 LYNDON B JOHNSON FWY STE 120
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6410
Mailing Address - Country:US
Mailing Address - Phone:214-433-2721
Mailing Address - Fax:
Practice Address - Street 1:6320 LYNDON B JOHNSON FWY STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6410
Practice Address - Country:US
Practice Address - Phone:214-433-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2023-12-06
Deactivation Date:2019-05-06
Deactivation Code:
Reactivation Date:2019-05-15
Provider Licenses
StateLicense IDTaxonomies
TX70750101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health