Healthcare Provider Details

I. General information

NPI: 1558547794
Provider Name (Legal Business Name): JACQUES D THIGPEN CERTIFIED/LICENSED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 BENJAMAN DRIVE
GREENVILLE NC
27834-1437
US

IV. Provider business mailing address

1221 BENJAMAN DR
GREENVILLE NC
27834-9352
US

V. Phone/Fax

Practice location:
  • Phone: 252-558-3139
  • Fax:
Mailing address:
  • Phone: 252-558-3139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number27054
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberJT873203
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: