Healthcare Provider Details

I. General information

NPI: 1730673864
Provider Name (Legal Business Name): JAMAAL OTHIOSSINIR LCSW-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2732 ANN ELIZABETH DR
BURLINGTON NC
27215-5111
US

IV. Provider business mailing address

1131 EDINBURGH DR
JAMESTOWN NC
27282-9058
US

V. Phone/Fax

Practice location:
  • Phone: 336-229-5905
  • Fax: 336-513-4203
Mailing address:
  • Phone: 336-470-4791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP012508
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: