MEDICARE: MRS. JESSICA DENISE HOLTON MSW, LCSW, LCAS

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	C005187	NC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	963	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	447992	OTHER	NC	TRICARE PIN
2	11612221	OTHER		CAQH UNIVERSAL DATA SOURC
3	56162	OTHER	NC	MEDCOST
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	142CH	OTHER	NC	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1780727909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA DENISE HOLTON MSW, LCSW, LCAS

Provider Business Mailing Address
First Line	:	740 GREENVILLE BLVD SE STE 400-208
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-5135
Country	:	US
Telephone Number	:	252-987-3039
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 GREENVILLE BLVD SE STE 400-208
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-5135
Country	:	US
Telephone Number	:	252-987-3039
Fax Number	:

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	11/29/2021

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