Healthcare Provider Details

I. General information

NPI: 1225775711
Provider Name (Legal Business Name): MALORI WHITE-JEFFERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 ROANOKE AVE
ELIZABETH CITY NC
27909-5643
US

IV. Provider business mailing address

3609 UNION ST
ELIZABETH CITY NC
27909-7057
US

V. Phone/Fax

Practice location:
  • Phone: 252-338-4370
  • Fax:
Mailing address:
  • Phone: 195-197-2549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: