MEDICARE: BLESSINDA JERMETTA STATON

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	A20629	NC

General Provider Information

NPI Number	:	1790612380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLESSINDA JERMETTA STATON

Provider Business Mailing Address
First Line	:	1523 HAMILTON HILLS DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-9812
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1523 HAMILTON HILLS DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-9812
Country	:	US
Telephone Number	:	336-558-0094
Fax Number	:

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

Provider Enumeration Date	:	05/06/2026
Last Update Date	:	05/06/2026

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