Provider Demographics
NPI:1558907063
Name:ROGERS, MARY JILLIAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JILLIAN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 CHINOE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-6571
Mailing Address - Country:US
Mailing Address - Phone:859-334-0884
Mailing Address - Fax:
Practice Address - Street 1:1050 CHINOE RD STE 106
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-6571
Practice Address - Country:US
Practice Address - Phone:859-334-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY266149103T00000X, 103TH0100X
KY244492103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103T00000XBehavioral Health & Social Service ProvidersPsychologist