Provider Demographics
NPI:1063928737
Name:JUBLOU, WENDY MARIE (LCASA, LPCA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:MARIE
Last Name:JUBLOU
Suffix:
Gender:F
Credentials:LCASA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 GREENVILLE BLVD SE, STE 400-164
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:223 COMMERCE ST STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5032
Practice Address - Country:US
Practice Address - Phone:252-758-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22870101YA0400X
NCA12896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)