Healthcare Provider Details

I. General information

NPI: 1134752207
Provider Name (Legal Business Name): JAIME WEATHERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10208 CERNY ST STE 110
RALEIGH NC
27617-7885
US

IV. Provider business mailing address

2000 PERIMETER PARK DR STE 200
MORRISVILLE NC
27560-8442
US

V. Phone/Fax

Practice location:
  • Phone: 984-215-4590
  • Fax: 984-215-4591
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP012404
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: