MEDICARE: JESSE SELKIN

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	103TC0700X	Clinical Psychologist	4996	NC

General Provider Information

NPI Number	:	1598014011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE SELKIN

Provider Business Mailing Address
First Line	:	8832 BLAKENEY PROFESSIONAL DR STE 105
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-6717
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8832 BLAKENEY PROFESSIONAL DR STE 105
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-6717
Country	:	US
Telephone Number	:	704-631-3980
Fax Number	:

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

Provider Enumeration Date	:	08/30/2012
Last Update Date	:	05/16/2020

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