Healthcare Provider Details

I. General information

NPI: 1750979332
Provider Name (Legal Business Name): VIBRANT LIFE COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W MARKET ST
GREENSBORO NC
27403-1829
US

IV. Provider business mailing address

6030 FORDING CREEK LN
KERNERSVILLE NC
27284-6347
US

V. Phone/Fax

Practice location:
  • Phone: 336-270-9501
  • Fax:
Mailing address:
  • Phone: 336-301-3426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENA PERKINS JOHNSON
Title or Position: OWNER
Credential: LCMCHA
Phone: 336-301-3426