1235078981 NPI number — JOVANCA NICOLE MCCOULLOUGH CADC

Table of content: JOVANCA NICOLE MCCOULLOUGH CADC (NPI 1235078981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235078981 NPI number — JOVANCA NICOLE MCCOULLOUGH CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCOULLOUGH
Provider First Name:
JOVANCA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235078981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 E FRANKLIN ST # 500
Provider Second Line Business Mailing Address:
ARCHDALE DRIVE
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28112-5160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-606-3182
Provider Business Mailing Address Fax Number:
704-317-3061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 E FRANKLIN ST # 500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28112-5160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-289-9869
Provider Business Practice Location Address Fax Number:
704-332-0124
Provider Enumeration Date:
03/27/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  14488 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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