Provider Demographics
NPI:1275296170
Name:ROGERS, JESSICA R (LPCA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1228
Mailing Address - Country:US
Mailing Address - Phone:270-991-5114
Mailing Address - Fax:
Practice Address - Street 1:901 BEAUTY AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-6135
Practice Address - Country:US
Practice Address - Phone:270-599-1034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY272282101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100762570Medicaid