Provider Demographics
NPI:1922568799
Name:MEDLOCK, JESSALYN (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSALYN
Middle Name:
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 RABBIT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:TN
Mailing Address - Zip Code:38222-4003
Mailing Address - Country:US
Mailing Address - Phone:731-441-1867
Mailing Address - Fax:
Practice Address - Street 1:6421 RABBIT CREEK RD
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:TN
Practice Address - Zip Code:38222-4003
Practice Address - Country:US
Practice Address - Phone:731-441-1867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X
TN11247104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker