Healthcare Provider Details

I. General information

NPI: 1649908740
Provider Name (Legal Business Name): ALICIA JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19300 STATESVILLE RD
CORNELIUS NC
28031-6764
US

IV. Provider business mailing address

1916 TOM SADLER RD
CHARLOTTE NC
28214-7461
US

V. Phone/Fax

Practice location:
  • Phone: 704-208-1855
  • Fax:
Mailing address:
  • Phone: 910-524-2205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024322
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: