Healthcare Provider Details

I. General information

NPI: 1669622510
Provider Name (Legal Business Name): JONATHAN HAYES FREEMAN FBPPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2594 REYNOLDA RD STE E
WINSTON SALEM NC
27106-4601
US

IV. Provider business mailing address

2594 REYNOLDA RD STE E
WINSTON SALEM NC
27106-4601
US

V. Phone/Fax

Practice location:
  • Phone: 336-655-7993
  • Fax:
Mailing address:
  • Phone: 336-655-7993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number74
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: