Provider Demographics
NPI:1124387329
Name:DIEDRICH, ASHLEY JESSICA (LPC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JESSICA
Last Name:DIEDRICH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:JESSICA
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:118 N 2ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2894
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:636-946-0991
Practice Address - Street 1:609 E HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2006
Practice Address - Country:US
Practice Address - Phone:580-765-0030
Practice Address - Fax:580-765-0073
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YA0400X
OK6314101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)