=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750979332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIBRANT LIFE COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2021
-----------------------------------------------------
Last Update Date | 04/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 W MARKET ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27403-1829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-270-9501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6030 FORDING CREEK LN
-----------------------------------------------------
City | KERNERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27284-6347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-301-3426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENA PERKINS JOHNSON
-----------------------------------------------------
Credential | LCMCHA
-----------------------------------------------------
Telephone | 336-301-3426
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------