Provider Demographics
NPI:1255590212
Name:BEAL KORHONEN, JESSICA K (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:K
Last Name:BEAL KORHONEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-3600
Mailing Address - Fax:502-588-9536
Practice Address - Street 1:210 E. GRAY ST.
Practice Address - Street 2:SUITE 601
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3902
Practice Address - Country:US
Practice Address - Phone:502-588-3600
Practice Address - Fax:502-588-9536
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1505103TC0700X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100069970Medicaid
IN200940980Medicaid