Healthcare Provider Details

I. General information

NPI: 1033990122
Provider Name (Legal Business Name): JENNIFER FAY MARINELLIE LCAS-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER FAY DAUBENMEYER

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MEMORIAL DR
PINEHURST NC
28374-8712
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-2040
  • Fax:
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-29419
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP019984
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: