1558449678 NPI number — MRS. JENNIFER MUNGLE TERRY MS, LPC, CRC

Table of content: MRS. JENNIFER MUNGLE TERRY MS, LPC, CRC (NPI 1558449678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558449678 NPI number — MRS. JENNIFER MUNGLE TERRY MS, LPC, CRC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TERRY
Provider First Name:
JENNIFER
Provider Middle Name:
MUNGLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC, CRC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558449678
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 OLD DOCK TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27519-6906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-389-0711
Provider Business Mailing Address Fax Number:
866-401-2407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 KEISLER DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27518-7097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-389-0711
Provider Business Practice Location Address Fax Number:
866-401-2407
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  4157 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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