MEDICARE: KATHARINE WHEELER JETT CRC, LPCA

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	101YM0800X	Mental Health Counselor	A12310	NC
2	101YP2500X	Professional Counselor	A12310	NC

General Provider Information

NPI Number	:	1346789674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHARINE WHEELER JETT CRC, LPCA

Provider Business Mailing Address
First Line	:	911 BRIDGES ST
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-3837
Country	:	US
Telephone Number	:	910-265-0769
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 COMMERCE AVE STE B
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-2952
Country	:	US
Telephone Number	:	252-499-9021
Fax Number	:

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

Provider Enumeration Date	:	02/20/2017
Last Update Date	:	02/20/2017

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