Provider Demographics
NPI:1558609602
Name:HENDRICKS, JESSICA MERIA (LCAS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MERIA
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 FLAGSTONE CT APT F2
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-8797
Mailing Address - Country:US
Mailing Address - Phone:252-314-4038
Mailing Address - Fax:
Practice Address - Street 1:400 GLENWOOD AVE STE 2
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501
Practice Address - Country:US
Practice Address - Phone:252-429-1837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2882-A101YA0400X
NCP0074861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)