Provider Demographics
NPI:1083195796
Name:LANE, JESSICA D (LPCC-S, LICDC-CS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:LANE
Suffix:
Gender:F
Credentials:LPCC-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-1843
Mailing Address - Country:US
Mailing Address - Phone:937-247-9015
Mailing Address - Fax:
Practice Address - Street 1:113 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-1843
Practice Address - Country:US
Practice Address - Phone:937-247-9015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1801141101YP2500X
OHLICDC.161705101YA0400X
OHE.2001904101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0309523Medicaid
14973982OtherCAQH