Healthcare Provider Details

I. General information

NPI: 1073424883
Provider Name (Legal Business Name): MYAKEYA KELLY JAMISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BAXTER ST STE 450&455
CHARLOTTE NC
28204-3053
US

IV. Provider business mailing address

515 PEPPERVINE LN
CHARLOTTE NC
28217-5290
US

V. Phone/Fax

Practice location:
  • Phone: 616-222-5607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: