1639657083 NPI number — SHEVONNA JETT LCMHC, LCAS, CSS-I

Table of content: SHEVONNA JETT LCMHC, LCAS, CSS-I (NPI 1639657083)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639657083 NPI number — SHEVONNA JETT LCMHC, LCAS, CSS-I

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
JETT

Provider First Name:
SHEVONNA

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
LCMHC, LCAS, CSS-I

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:
1639657083

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
06/13/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3315 WILKINSON BLVD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
CHARLOTTE

Provider Business Mailing Address State Name:
NC

Provider Business Mailing Address Postal Code:
28208-5631

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
704-697-0044

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1935 J N PEASE PL STE 104

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
CHARLOTTE

Provider Business Practice Location Address State Name:
NC

Provider Business Practice Location Address Postal Code:
28262-4541

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
704-548-5298

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
07/29/2018

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: 24807 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 101YP2500X , with the licence number: A14034 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .