Healthcare Provider Details

I. General information

NPI: 1194916288
Provider Name (Legal Business Name): GERALD W LANKFORD JR. MBA, MACC, MDIV, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JERRY LANKFORD MBA, MACC, ,LPC

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 JONES FRANKLIN RD SUITE 104
RALEIGH NC
27606-3379
US

IV. Provider business mailing address

1601 JONES FRANKLIN RD SUITE 104
RALEIGH NC
27606-3379
US

V. Phone/Fax

Practice location:
  • Phone: 919-851-1527
  • Fax: 919-851-3555
Mailing address:
  • Phone: 919-851-1527
  • Fax: 919-851-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number6654
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6654
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: