MEDICARE: MRS. JACQUELINE FADEYI-BRYANT LCSW

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	C002905	NC

General Provider Information

NPI Number	:	1558426213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELINE FADEYI-BRYANT LCSW

Provider Business Mailing Address
First Line	:	200 VALENCIA DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6311
Country	:	US
Telephone Number	:	910-353-3060
Fax Number	:	910-353-3080

Provider Business Practice Location Address
First Line	:	200 VALENCIA DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6311
Country	:	US
Telephone Number	:	910-353-3060
Fax Number	:	910-353-3080

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

Provider Enumeration Date	:	12/23/2006
Last Update Date	:	02/17/2017

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