1306937750 NPI number — MR. JON WAYNE ECCLESTON II LCSW

Table of content: MR. JON WAYNE ECCLESTON II LCSW (NPI 1306937750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306937750 NPI number — MR. JON WAYNE ECCLESTON II LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ECCLESTON
Provider First Name:
JON
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
II
Provider Credential Text:
LCSW
Provider Gender Code:
M

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:
1306937750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 UNIONVILLE INDIAN TRL RD W
Provider Second Line Business Mailing Address:
SUITE A1
Provider Business Mailing Address City Name:
INDIAN TRAIL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28079-5591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-608-0445
Provider Business Mailing Address Fax Number:
704-821-9337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 UNIONVILLE INDIAN TRL RD W
Provider Second Line Business Practice Location Address:
SUITE A1
Provider Business Practice Location Address City Name:
INDIAN TRAIL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28079-5591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-608-0445
Provider Business Practice Location Address Fax Number:
704-821-9337
Provider Enumeration Date:
09/28/2006

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: 1041C0700X , with the licence number:  C004734 , 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)

  • Identifier: C004734 . This is a "NC CLINICAL SOCIAL WORK" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 600913 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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