Provider Demographics
NPI:1679244891
Name:BURGE, JESSICA (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BURGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4522 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2332
Mailing Address - Country:US
Mailing Address - Phone:330-915-2907
Mailing Address - Fax:330-915-2958
Practice Address - Street 1:4522 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2332
Practice Address - Country:US
Practice Address - Phone:330-915-2907
Practice Address - Fax:330-915-2958
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406219101Y00000X, 101YP2500X
OHC.2304818-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077615Medicaid