Healthcare Provider Details

I. General information

NPI: 1215628706
Provider Name (Legal Business Name): JATAIME SHADALE TAYLOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 COPPERFIELD BLVD NE
CONCORD NC
28025-2426
US

IV. Provider business mailing address

403 PEWTER CT
JACKSONVILLE NC
28546-5000
US

V. Phone/Fax

Practice location:
  • Phone: 704-940-2877
  • Fax: 704-897-8980
Mailing address:
  • Phone: 910-382-1697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC019825
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: