Basic Information
| Provider Information | |||||||||
| NPI: | 1275821662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASKINS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | SANDERS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRESCOTT | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | SANDERS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 110-B BRANCHWOOD DR. | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109389833 | ||||||||
| FaxNumber: | 9109389835 | ||||||||
| Practice Location | |||||||||
| Address1: | 110-B BRANCHWOOD DR. | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285845900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109389833 | ||||||||
| FaxNumber: | 9109389835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 09/12/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 097.0078502 | VT | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | 12832 | NC | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.