Provider Demographics
NPI:1205119575
Name:PACK, JESSICA K (MHA, MS, LGC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:K
Last Name:PACK
Suffix:
Gender:F
Credentials:MHA, MS, LGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3139
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-3139
Mailing Address - Country:US
Mailing Address - Phone:888-252-2842
Mailing Address - Fax:502-470-3645
Practice Address - Street 1:4330 GLENVIEW AVENUE
Practice Address - Street 2:#111
Practice Address - City:GLENVIEW
Practice Address - State:KY
Practice Address - Zip Code:40025-0111
Practice Address - Country:US
Practice Address - Phone:888-252-2842
Practice Address - Fax:502-470-3645
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN74000172AOtherGENETIC COUNSELING LICENSE
NE96OtherGENETIC COUNSELING LICENSE