=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235078981
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOVANCA NICOLE MCCOULLOUGH CADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2026
-----------------------------------------------------
Last Update Date | 03/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1410 E FRANKLIN ST # 500
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28112-5160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-289-9869
-----------------------------------------------------
Fax | 704-332-0124
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1410 E FRANKLIN ST # 500 ARCHDALE DRIVE
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28112-5160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-606-3182
-----------------------------------------------------
Fax | 704-317-3061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 14488
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------