Provider Demographics
NPI:1073848750
Name:THARP, JERALYN RENEE (LPCC-S LICDC)
Entity Type:Individual
Prefix:
First Name:JERALYN
Middle Name:RENEE
Last Name:THARP
Suffix:
Gender:F
Credentials:LPCC-S LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 WOODSIDE DR STE A
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1848
Mailing Address - Country:US
Mailing Address - Phone:937-540-9495
Mailing Address - Fax:937-962-6210
Practice Address - Street 1:609 WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1848
Practice Address - Country:US
Practice Address - Phone:937-540-9495
Practice Address - Fax:937-962-6210
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1800797101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHG0332295Medicaid
OHG0332295OtherMEDICAID