MEDICARE: MRS. JACQUETTA RESHON COLEMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1093904021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUETTA RESHON COLEMAN

Provider Business Mailing Address
First Line	:	10926 DAVID TAYLOR DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1293
Country	:	US
Telephone Number	:	980-217-3340
Fax Number	:

Provider Business Practice Location Address
First Line	:	10926 DAVID TAYLOR DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1293
Country	:	US
Telephone Number	:	980-217-3340
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	08/12/2024

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