Healthcare Provider Details

I. General information

NPI: 1427469295
Provider Name (Legal Business Name): LAURA JEANE WRINKLE CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 PINEWOOD DR
JACKSONVILLE NC
28546-7707
US

IV. Provider business mailing address

806 BELL FORK RD
JACKSONVILLE NC
28540-6312
US

V. Phone/Fax

Practice location:
  • Phone: 717-577-8504
  • Fax:
Mailing address:
  • Phone: 910-347-2205
  • Fax: 910-347-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2925
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: