Healthcare Provider Details

I. General information

NPI: 1083525414
Provider Name (Legal Business Name): SEA GLASS COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 EASTWOOD RD STE 307
WILMINGTON NC
28403-7228
US

IV. Provider business mailing address

7019 CAYMAN CT
WILMINGTON NC
28405-8371
US

V. Phone/Fax

Practice location:
  • Phone: 910-408-5490
  • Fax:
Mailing address:
  • Phone: 910-620-8276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER KEEVER PETERKEN
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 910-620-8276