MEDICARE: JACQUELYNE AIDA TINGEY

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	1041C0700X	Clinical Social Worker	P014913	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	38981783	OTHER	NC	DRIVER'S LICENSE

General Provider Information

NPI Number	:	1366050239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYNE AIDA TINGEY

Provider Business Mailing Address
First Line	:	5950 FAIRVIEW RD STE 660
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-3113
Country	:	US
Telephone Number	:	562-310-3391
Fax Number	:	704-909-4009

Provider Business Practice Location Address
First Line	:	5950 FAIRVIEW RD STE 660
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-3113
Country	:	US
Telephone Number	:	562-310-3391
Fax Number	:	704-909-4009

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

Provider Enumeration Date	:	07/16/2020
Last Update Date	:	07/16/2020

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Directions to “ JACQUELYNE AIDA TINGEY ” Practice Location

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