Healthcare Provider Details

I. General information

NPI: 1952827792
Provider Name (Legal Business Name): JESSICA WYCKOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 N NC 241 HWY
BEULAVILLE NC
28518-8636
US

IV. Provider business mailing address

2618 PINEWOOD HOME DR
PINK HILL NC
28572-9648
US

V. Phone/Fax

Practice location:
  • Phone: 910-298-2331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number18475
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: