Provider Demographics
NPI:1689853491
Name:ERICKSON, JESSICA LEIGH (MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 JUSTICE LN
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-8253
Mailing Address - Country:US
Mailing Address - Phone:307-250-7522
Mailing Address - Fax:
Practice Address - Street 1:147 COOPER LN E
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9233
Practice Address - Country:US
Practice Address - Phone:307-250-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1145101YP2500X, 101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY131309601Medicaid