Healthcare Provider Details

I. General information

NPI: 1659940823
Provider Name (Legal Business Name): JEM BEHAVIORAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5960 FAIRVIEW RD STE 400
CHARLOTTE NC
28210-3119
US

IV. Provider business mailing address

5960 FAIRVIEW RD STE 400
CHARLOTTE NC
28210-3119
US

V. Phone/Fax

Practice location:
  • Phone: 704-267-6905
  • Fax:
Mailing address:
  • Phone: 980-483-3015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: VANESSA GRAHAM
Title or Position: OWNER
Credential: FNP/PMHNP
Phone: 980-483-3015