Basic Information
| Provider Information | |||||||||
| NPI: | 1508178872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | STERLING | ||||||||
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| Credential: | LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 S MANGUM ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277013904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196831607 | ||||||||
| FaxNumber: | 9196831790 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 S MANGUM ST | ||||||||
| Address2: | SUITE C1 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277013904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196831607 | ||||||||
| FaxNumber: | 9196831790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2010 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6112297 | 05 | NC | MEDICAID |