Basic Information
| Provider Information | |||||||||
| NPI: | 1356402135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFEY | ||||||||
| FirstName: | JAROD | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 FAIRFAX AVE | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288063223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283370071 | ||||||||
| FaxNumber: | 8283501188 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 BILTMORE AVE STE 2E | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288014540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283501177 | ||||||||
| FaxNumber: | 8283501188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS 1549 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | LCSW C004949 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | C004949 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6003407 | 05 | NC | MEDICAID |