Healthcare Provider Details

I. General information

NPI: 1003574237
Provider Name (Legal Business Name): JENNIFER DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1482 RUSS AVE
WAYNESVILLE NC
28786-4143
US

IV. Provider business mailing address

91 LEATHERWOOD ST
WAYNESVILLE NC
28786-3385
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-1395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP017124
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: