Healthcare Provider Details

I. General information

NPI: 1275443210
Provider Name (Legal Business Name): JAYLA SIMONE THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 LATROBE DR
CHARLOTTE NC
28211-4824
US

IV. Provider business mailing address

12033 CHANTRESS LN
CHARLOTTE NC
28215-8077
US

V. Phone/Fax

Practice location:
  • Phone: 704-222-4238
  • Fax:
Mailing address:
  • Phone: 704-222-4238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP023957
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: