Healthcare Provider Details

I. General information

NPI: 1184984510
Provider Name (Legal Business Name): JASMINE SHAVON BETHEA MSW,LCSW,LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ONYX CT
DURHAM NC
27703-2680
US

IV. Provider business mailing address

8041 BRIER CREEK PKWY # 1046
DURHAM NC
27703-2680
US

V. Phone/Fax

Practice location:
  • Phone: 919-408-4945
  • Fax:
Mailing address:
  • Phone: 919-408-4945
  • Fax: 919-913-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC018890
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-28029
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149030065
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: