Provider Demographics
NPI:1063697118
Name:DEACON, JENNIFER M (PSYCH ASSOCIATE)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:DEACON
Suffix:
Gender:F
Credentials:PSYCH ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-3727
Mailing Address - Country:US
Mailing Address - Phone:828-433-8084
Mailing Address - Fax:
Practice Address - Street 1:512 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-3727
Practice Address - Country:US
Practice Address - Phone:828-403-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-12-12257103K00000X, 103K00000X
NC1982103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107547Medicaid