Basic Information
| Provider Information | |||||||||
| NPI: | 1477792521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VUNCANNON | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PH.D., LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 ARSENAL AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103233368 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 ARSENAL AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103233368 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2009 | ||||||||
| LastUpdateDate: | 06/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6104128 | 05 | NC | MEDICAID |