Basic Information
| Provider Information | |||||||||
| NPI: | 1235416215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | CRC, LCAS, LPC, MAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4238 DUDLEYS GRANT DR APT C | ||||||||
| Address2: | |||||||||
| City: | WINTERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285907942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527027503 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 PALADIN DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278347826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523535346 | ||||||||
| FaxNumber: | 2523217300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 10900 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 168173 | KY | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 2062 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 10900 | 01 | NC | LPC | OTHER | 2062 | 01 | NC | LCAS | OTHER |