Provider Demographics
NPI:1386027522
Name:FROEDGE, JESSICA R (LPCC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:FROEDGE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-250-2422
Mailing Address - Fax:
Practice Address - Street 1:302 BRUMMAL AVENUE
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-1004
Practice Address - Country:US
Practice Address - Phone:844-435-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY284710101YP2500X
KY268560101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
15913106OtherCAQH