=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447806054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLYN NICOLE JONES LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2019
-----------------------------------------------------
Last Update Date | 05/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4412 PARK RD STE B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28209-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-217-6901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3811 VINING CT
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28216-3116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-457-4324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C015631
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------