Provider Demographics
NPI:1669128237
Name:ETHREDGE, MEGAN ELISE (LPC/MHSP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELISE
Last Name:ETHREDGE
Suffix:
Gender:F
Credentials:LPC/MHSP
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:ELISE
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC/MHSP
Mailing Address - Street 1:48 SPRINGFIELD CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-9779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:367B N PARKWAY STE 1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2899
Practice Address - Country:US
Practice Address - Phone:731-668-2277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5734101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional