Healthcare Provider Details

I. General information

NPI: 1083153183
Provider Name (Legal Business Name): JESSIE DEUSSING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 J N PEASE PL SUITE 204
CHARLOTTE NC
28262-4554
US

IV. Provider business mailing address

1935 J N PEASE PL SUITE 204
CHARLOTTE NC
28262-4554
US

V. Phone/Fax

Practice location:
  • Phone: 704-755-4392
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA12789
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: