=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467741918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELYN RENEE HARTMAN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2011
-----------------------------------------------------
Last Update Date | 06/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 WINDEL DR
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-4475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-867-4042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 DEER VIEW DR
-----------------------------------------------------
City | WILLOW SPRING
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27592-8559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-867-4042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 8527
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------