Healthcare Provider Details

I. General information

NPI: 1346883543
Provider Name (Legal Business Name): JESSICA MARIE SOLIS SLOAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 LAKE BOONE TRL STE 201
RALEIGH NC
27607-7511
US

IV. Provider business mailing address

4201 LAKE BOONE TRL STE 201
RALEIGH NC
27607-7511
US

V. Phone/Fax

Practice location:
  • Phone: 919-442-1123
  • Fax: 919-785-0038
Mailing address:
  • Phone: 919-442-1123
  • Fax: 919-785-0038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5428
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: