Provider Demographics
NPI:1578113353
Name:HERBST, JESSICA ANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:HERBST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 DUNAWAY ST
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3833
Mailing Address - Country:US
Mailing Address - Phone:937-336-7686
Mailing Address - Fax:
Practice Address - Street 1:1112 GALLIA ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4161
Practice Address - Country:US
Practice Address - Phone:317-674-0981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00977103K00000X
KY287507103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst