Basic Information
| Provider Information | |||||||||
| NPI: | 1245435734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | GAYLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 W BLACKBEARD RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284092708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104527115 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2450 DELANEY RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107639512 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2177 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.