Provider Demographics
NPI:1205810306
Name:HERSCH, C JESSICA (LCSW LMFT ACSW)
Entity type:Individual
Prefix:
First Name:C JESSICA
Middle Name:
Last Name:HERSCH
Suffix:
Gender:F
Credentials:LCSW LMFT ACSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:HERSCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW LMFT ACSW
Mailing Address - Street 1:115 N COLLEGE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3933
Mailing Address - Country:US
Mailing Address - Phone:812-327-9209
Mailing Address - Fax:
Practice Address - Street 1:115 N COLLEGE AVE STE 113
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3933
Practice Address - Country:US
Practice Address - Phone:812-332-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002313101YM0800X, 1041C0700X
IN35001129106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN546470YYMedicare ID - Type Unspecified
IN541910HHHHMedicare ID - Type Unspecified
IN562970LLMedicare ID - Type Unspecified
IN601530EMedicare ID - Type Unspecified
IN562950AAMedicare ID - Type Unspecified