MEDICARE: JEAN MICHELLE WILCOX LCMHCA

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	A15070	NC
2	101YP2500X	Professional Counselor	A15070	NC

General Provider Information

NPI Number	:	1356997837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN MICHELLE WILCOX LCMHCA

Provider Business Mailing Address
First Line	:	PO BOX 756
Second Line	:
City	:	HARRISBURG
State	:	NC
Zip	:	28075-0756
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5104 REAGAN DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28206-1396
Country	:	US
Telephone Number	:	704-281-6277
Fax Number	:

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

Provider Enumeration Date	:	08/12/2019
Last Update Date	:	04/09/2021

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