MEDICARE: JENNIFER DIANNE CONRAD

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	101YM0800X	Mental Health Counselor	A18124	NC

General Provider Information

NPI Number	:	1447007570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DIANNE CONRAD

Provider Business Mailing Address
First Line	:	407 N SUMNER ST
Second Line	:
City	:	SELMA
State	:	NC
Zip	:	27576-2530
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7621 PURFOY RD STE 105B
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-6985
Country	:	US
Telephone Number	:	833-749-4584
Fax Number	:

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

Provider Enumeration Date	:	05/06/2024
Last Update Date	:	05/06/2024

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Directions to “ JENNIFER DIANNE CONRAD ” Practice Location

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