Provider Demographics
NPI:1912358359
Name:HUMPHREY, JESSICA R
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:HUMPHREY
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 1:1911B SCOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3303
Mailing Address - Country:US
Mailing Address - Phone:270-535-1245
Mailing Address - Fax:
Practice Address - Street 1:1911B SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3303
Practice Address - Country:US
Practice Address - Phone:270-535-1245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7617104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker