MEDICARE: MS. JAMESE NICOLE GRANT MSW, LCSW-A

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	P007946	NC

General Provider Information

NPI Number	:	1467860361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JAMESE NICOLE GRANT MSW, LCSW-A

Provider Business Mailing Address
First Line	:	5700 EXECUTIVE CENTER DR STE 101
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-8833
Country	:	US
Telephone Number	:	704-537-1022
Fax Number	:	704-569-0822

Provider Business Practice Location Address
First Line	:	5700 EXECUTIVE CENTER DR STE 101
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-8833
Country	:	US
Telephone Number	:	704-537-1022
Fax Number	:	704-569-0822

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

Provider Enumeration Date	:	07/24/2014
Last Update Date	:	07/24/2014

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