Healthcare Provider Details

I. General information

NPI: 1174366728
Provider Name (Legal Business Name): JESSICA WURSTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5046 GRAYS CREEK CHURCH RD
HOPE MILLS NC
28348-7812
US

IV. Provider business mailing address

920 CAMBRIDGE ST
FAYETTEVILLE NC
28303-5300
US

V. Phone/Fax

Practice location:
  • Phone: 910-493-3555
  • Fax:
Mailing address:
  • Phone: 910-493-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP022583
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: