Provider Demographics
NPI:1649039819
Name:MEDINA, JESSICA SUE (LPCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2290
Mailing Address - Country:US
Mailing Address - Phone:719-587-1060
Mailing Address - Fax:719-587-1525
Practice Address - Street 1:100 KENDALL DR
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-3901
Practice Address - Country:US
Practice Address - Phone:719-384-5446
Practice Address - Fax:719-336-7453
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21791101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional