Healthcare Provider Details

I. General information

NPI: 1073385142
Provider Name (Legal Business Name): JAYQUANE D WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8521 SIX FORKS RD
RALEIGH NC
27615-5278
US

IV. Provider business mailing address

19401 40TH AVE W STE 100
LYNNWOOD WA
98036-5600
US

V. Phone/Fax

Practice location:
  • Phone: 919-676-3118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: