Healthcare Provider Details

I. General information

NPI: 1730617580
Provider Name (Legal Business Name): JODECI MARIE OQUENDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 EAST BLVD STE E1778
CHARLOTTE NC
28203-5870
US

IV. Provider business mailing address

1235 EAST BLVD STE E1778
CHARLOTTE NC
28203-5870
US

V. Phone/Fax

Practice location:
  • Phone: 860-253-2449
  • Fax:
Mailing address:
  • Phone: 860-253-2449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6367
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19040
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11738
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: