Provider Demographics
NPI:1275971186
Name:KETOLA, JESSICA HAASE (LPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HAASE
Last Name:KETOLA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 RIVERBEND DR STE 2
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8695
Mailing Address - Country:US
Mailing Address - Phone:434-249-9028
Mailing Address - Fax:434-961-2556
Practice Address - Street 1:125 RIVERBEND DR STE 2
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8695
Practice Address - Country:US
Practice Address - Phone:434-249-9028
Practice Address - Fax:434-961-2556
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005483101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional