MEDICARE: MISS JEWELL THOMPSON M.S, QMHP, CADC, PSS

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	171M00000X	Case Manager/Care Coordinator
2	175T00000X	Peer Specialist	2023-10462-01	NC
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	25110	NC

General Provider Information

NPI Number	:	1437534914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JEWELL THOMPSON M.S, QMHP, CADC, PSS

Provider Business Mailing Address
First Line	:	2166 GOLD HILL RD STE 4
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-9351
Country	:	US
Telephone Number	:	704-819-0464
Fax Number	:	803-973-0207

Provider Business Practice Location Address
First Line	:	436 E 36TH ST
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1030
Country	:	US
Telephone Number	:	704-819-0464
Fax Number	:	803-973-0207

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

Provider Enumeration Date	:	07/24/2015
Last Update Date	:	07/27/2024

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