Provider Demographics
NPI:1073195327
Name:JENNETTE, CANDACE CHARLISA (MASTER'S EDUCATION)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:CHARLISA
Last Name:JENNETTE
Suffix:
Gender:F
Credentials:MASTER'S EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MARSH GRASS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2194
Mailing Address - Country:US
Mailing Address - Phone:919-389-7686
Mailing Address - Fax:
Practice Address - Street 1:700 MARSH GRASS DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2194
Practice Address - Country:US
Practice Address - Phone:919-389-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child