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General NPI Number Information
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NPI Number | 1760862262
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Entity Type | Organization
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Legal Business Name | RALEIGH PSYCHOLOGICAL ASSOCIATES
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Dates
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Enumeration Date | 06/01/2015
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Last Update Date | 06/01/2015
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Provider Practice Location Address
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Address Line | 122 W VERNON AVE
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City | WAKE FOREST
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State | NC
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Zip | 27587-2816
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Country | US
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Telephone | 919-274-4476
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Fax | 919-554-9232
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Provider Business Mailing Address
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Address Line | 122 W VERNON AVE
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City | WAKE FOREST
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State | NC
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Zip | 27587-2816
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Country | US
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Telephone | 919-274-4476
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Fax | 919-554-9232
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JACKELIN JENNIFER VELOZ JEFFERSON
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Credential | LPA, ED.S.
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Telephone | 919-274-4476
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 2501
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License Number State | NC
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