Healthcare Provider Details

I. General information

NPI: 1487133351
Provider Name (Legal Business Name): COASTAL RIDGE HEALTH SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14057 US HIGHWAY 17 STE 200
HAMPSTEAD NC
28443-3793
US

IV. Provider business mailing address

14057 US HIGHWAY 17 STE 200
HAMPSTEAD NC
28443-3793
US

V. Phone/Fax

Practice location:
  • Phone: 910-821-1418
  • Fax: 866-860-0997
Mailing address:
  • Phone: 910-821-1418
  • Fax: 866-860-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4461S
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024175505
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5009986
License Number StateNC

VIII. Authorized Official

Name: DR. DEBORAH S JENKS
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential: DNP, PMHNP-BC, FNP
Phone: 910-821-1418