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General NPI Number Information
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NPI Number | 1811539786
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Entity Type | Individual
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Provider Name | JESSEYETTA LAVETTA STATON LCSWA
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Gender | Female
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Dates
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Enumeration Date | 10/11/2019
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Last Update Date | 10/11/2019
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Provider Practice Location Address
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Address Line | 2015 AYRSLEY TOWN BLVD STE 202
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City | CHARLOTTE
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State | NC
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Zip | 28273-4068
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Country | US
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Telephone | 888-547-9905
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Fax |
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Provider Business Mailing Address
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Address Line | 7110 LOWEN RD
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City | CHARLOTTE
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State | NC
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Zip | 28269-0194
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Country | US
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Telephone | 704-615-4183
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | P014185
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License Number State | NC
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