Provider Demographics
NPI:1225180664
Name:EDWARDS, JOHN DEXTER (LPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DEXTER
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:JODEY
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:187 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-8125
Mailing Address - Country:US
Mailing Address - Phone:318-547-9627
Mailing Address - Fax:318-322-9492
Practice Address - Street 1:1410 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5608
Practice Address - Country:US
Practice Address - Phone:318-998-3511
Practice Address - Fax:318-322-9492
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3379101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$0OtherBLUE CROSS ID