Healthcare Provider Details

I. General information

NPI: 1245879022
Provider Name (Legal Business Name): JADE INTEGRATIVE COUNSELING AND WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2019
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5970 FAIRVIEW RD STE 420
CHARLOTTE NC
28210-3167
US

IV. Provider business mailing address

5970 FAIRVIEW RD STE 420
CHARLOTTE NC
28210-3167
US

V. Phone/Fax

Practice location:
  • Phone: 980-701-4192
  • Fax: 980-701-4194
Mailing address:
  • Phone: 980-701-4192
  • Fax: 980-701-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHARRYSE A JOHNSON
Title or Position: OWNER
Credential: MA, LPC
Phone: 980-701-4192