Basic Information
| Provider Information | |||||||||
| NPI: | 1689218828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 401 MOYE BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278342885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528302149 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 MOYE BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278342885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528302149 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2019 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 103250 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TH0004X | 103250 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Health | 103TH0100X | 103250 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TC0700X | 103250 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.