Healthcare Provider Details

I. General information

NPI: 1427488295
Provider Name (Legal Business Name): JACLYN FORTIER M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACLYN FORTIER M.A.

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 PEMBERTON HILL RD SUITE 202
APEX NC
27502
US

IV. Provider business mailing address

1011 PEMBERTON HILL RD STE 202
APEX NC
27502
US

V. Phone/Fax

Practice location:
  • Phone: 919-410-3852
  • Fax:
Mailing address:
  • Phone: 919-410-3852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14288
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: