Healthcare Provider Details

I. General information

NPI: 1770536054
Provider Name (Legal Business Name): COLONY BEHAVIORAL HEALTH GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 VILLAGE WAY
TRENT WOODS NC
28562-7305
US

IV. Provider business mailing address

2804 VILLAGE WAY
TRENT WOODS NC
28562-7305
US

V. Phone/Fax

Practice location:
  • Phone: 252-636-0112
  • Fax: 252-634-9778
Mailing address:
  • Phone: 252-636-0112
  • Fax: 252-634-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2021
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC1030
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberPCAS28
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3037
License Number StateNC

VIII. Authorized Official

Name: DR. BETHANNE THUMM JACOBSON
Title or Position: LICENSED PSYCHOLOGIST
Credential: PH.D.
Phone: 252-636-0112