MEDICARE: JESICA DEMUMBREUM MSN, PMHNP-BC, IBCLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5017873	NC

General Provider Information

NPI Number	:	1679985683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESICA DEMUMBREUM MSN, PMHNP-BC, IBCLC

Provider Business Mailing Address
First Line	:	1977 J.N. PLEASE PLACE
Second Line	:	SUITE 202
City	:	CHARLOTTE
State	:	NC
Zip	:	28262
Country	:	US
Telephone Number	:	704-817-8230
Fax Number	:	704-665-5645

Provider Business Practice Location Address
First Line	:	1977 J N PEASE PL STE 202
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4527
Country	:	US
Telephone Number	:	704-817-8230
Fax Number	:	704-665-5645

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

Provider Enumeration Date	:	05/24/2014
Last Update Date	:	09/21/2023

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