Basic Information
Provider Information | |||||||||
NPI: | 1003216995 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIMMS | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | ALAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 296 MAHOGANY DR | ||||||||
Address2: | APT/SUITE | ||||||||
City: | THOMASVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 273609720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3364751798 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8025 N POINT BLVD STE 209 | ||||||||
Address2: |   | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271063296 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8667001606 | ||||||||
FaxNumber: | 8663385921 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2014 | ||||||||
LastUpdateDate: | 07/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 10896 | NC | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 10896 | NC | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.