Healthcare Provider Details

I. General information

NPI: 1952990228
Provider Name (Legal Business Name): JESSICA YOUNG LCMHC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA HEGE

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6614 SHALLOWFORD RD STE 250
LEWISVILLE NC
27023-9305
US

IV. Provider business mailing address

6614 SHALLOWFORD RD STE 250
LEWISVILLE NC
27023-9305
US

V. Phone/Fax

Practice location:
  • Phone: 336-251-8828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA16220
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA16220
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: