Healthcare Provider Details

I. General information

NPI: 1992482590
Provider Name (Legal Business Name): JORDAN NICOLE ROELS LCMHC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 W 5TH ST
WINSTON SALEM NC
27101-2506
US

IV. Provider business mailing address

860 W 5TH ST
WINSTON SALEM NC
27101-2506
US

V. Phone/Fax

Practice location:
  • Phone: 336-310-9515
  • Fax:
Mailing address:
  • Phone: 336-310-9515
  • Fax: 335-780-7344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17823
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: