Provider Demographics
NPI:1417325960
Name:BURNS, JERICA (LMHC)
Entity Type:Individual
Prefix:
First Name:JERICA
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:JERICA
Other - Middle Name:
Other - Last Name:TRIPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0809
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:2600 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-1533
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002682A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health