Healthcare Provider Details

I. General information

NPI: 1073255055
Provider Name (Legal Business Name): PROVISIONS2LIVE BEHAVIORAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3622 LYCKAN PKWY STE 4006
DURHAM NC
27707-2566
US

IV. Provider business mailing address

3622 LYCKAN PKWY STE 4006
DURHAM NC
27707-2566
US

V. Phone/Fax

Practice location:
  • Phone: 919-390-1398
  • Fax: 919-910-5668
Mailing address:
  • Phone: 919-390-1398
  • Fax: 919-910-5668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER INEZ MCLEAN-RUSS
Title or Position: PMH-NP
Credential: MSN/NP
Phone: 919-638-4115