Healthcare Provider Details

I. General information

NPI: 1548032105
Provider Name (Legal Business Name): JENNY COBLE GUM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 NC 62
BURLINGTON NC
27258
US

IV. Provider business mailing address

3157 S JIM MINOR RD
HAW RIVER NC
27258-9757
US

V. Phone/Fax

Practice location:
  • Phone: 336-264-4892
  • Fax:
Mailing address:
  • Phone: 336-264-4892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCOO4250
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: