Basic Information
Provider Information | |||||||||
NPI: | 1124230586 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOEHLECKE | ||||||||
FirstName: | JEANNE | ||||||||
MiddleName: | GRESKO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRESKO | ||||||||
OtherFirstName: | JEANNE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 608 CHURCHILL DR | ||||||||
Address2: |   | ||||||||
City: | CHAPEL HILL | ||||||||
State: | NC | ||||||||
PostalCode: | 275172505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199427909 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 115 TIMBERHILL PL | ||||||||
Address2: |   | ||||||||
City: | CHAPEL HILL | ||||||||
State: | NC | ||||||||
PostalCode: | 275141586 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199675959 | ||||||||
FaxNumber: | 9199681478 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.