Provider Demographics
NPI:1396245262
Name:LICHT, JESSICA DIANNE
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DIANNE
Last Name:LICHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:DIANNE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD SUITE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:126 PAVILION PARKWAY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1268
Practice Address - Country:US
Practice Address - Phone:770-954-8988
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2018-02-17
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4962103K00000X, 103K00000X
GA1-22-58490103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst