MEDICARE: JENNY M. CAMILO CSAC-24946

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CSAC-24946	NC

General Provider Information

NPI Number	:	1356828180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNY M. CAMILO CSAC-24946

Provider Business Mailing Address
First Line	:	5601 SORRELL CROSSING DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27617-8301
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2231 E MILLBROOK RD STE 101
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-1746
Country	:	US
Telephone Number	:	919-307-8165
Fax Number	:	919-307-8167

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

Provider Enumeration Date	:	07/24/2018
Last Update Date	:	07/24/2018

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