Healthcare Provider Details

I. General information

NPI: 1306937750
Provider Name (Legal Business Name): JON WAYNE ECCLESTON II LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 UNIONVILLE INDIAN TRL RD W SUITE A1
INDIAN TRAIL NC
28079-5591
US

IV. Provider business mailing address

124 UNIONVILLE INDIAN TRL RD W SUITE A1
INDIAN TRAIL NC
28079-5591
US

V. Phone/Fax

Practice location:
  • Phone: 704-608-0445
  • Fax: 704-821-9337
Mailing address:
  • Phone: 704-608-0445
  • Fax: 704-821-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004734
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: