MEDICARE: MS. JEMARIAN CHANTINEL BLAIR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	10008A	NC

General Provider Information

NPI Number	:	1174301568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEMARIAN CHANTINEL BLAIR

Provider Business Mailing Address
First Line	:	7015 FRYE PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-2811
Country	:	US
Telephone Number	:	980-293-6009
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 EXECUTIVE CENTER DR STE 118
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-8851
Country	:	US
Telephone Number	:	980-777-3650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	10/02/2023

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