Healthcare Provider Details

I. General information

NPI: 1649114968
Provider Name (Legal Business Name): JAMARA MYIA RICHARDSON LSCWA, LCASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S 2ND ST
SAINT PAULS NC
28384-1507
US

IV. Provider business mailing address

5695 ARCHER RD
HOPE MILLS NC
28348-2250
US

V. Phone/Fax

Practice location:
  • Phone: 910-633-4721
  • Fax:
Mailing address:
  • Phone: 757-710-9575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-31524
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP023508
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: