Basic Information
| Provider Information | |||||||||
| NPI: | 1487998522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLIFFORD | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | JARRETT | ||||||||
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| Credential: | LPC, LCAS-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 CRUTCHFIELD ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195607305 | ||||||||
| FaxNumber: | 9197971960 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 CRUTCHFIELD ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195607305 | ||||||||
| FaxNumber: | 9197971960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 08/25/2015 | ||||||||
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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 | 101YM0800X | 8743 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 8743 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 22065 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1487998522 | 05 | NC | MEDICAID |