Provider Demographics
NPI:1710498167
Name:RUTLIN, JERISHA LACRAE (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:JERISHA
Middle Name:LACRAE
Last Name:RUTLIN
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1872 WOODHOLLOW DR APT 211
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-3957
Mailing Address - Country:US
Mailing Address - Phone:314-625-6070
Mailing Address - Fax:
Practice Address - Street 1:1872 WOODHOLLOW DR APT 211
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-3957
Practice Address - Country:US
Practice Address - Phone:314-625-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015006047101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health