Provider Demographics
NPI:1336775774
Name:CORDLE, JESSICA (MS, CTRS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CORDLE
Suffix:
Gender:F
Credentials:MS, CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4078 E BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-9176
Mailing Address - Country:US
Mailing Address - Phone:706-969-2984
Mailing Address - Fax:
Practice Address - Street 1:5665 HOOVER RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9280
Practice Address - Country:US
Practice Address - Phone:706-969-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
65528225800000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist