Provider Demographics
NPI:1104109123
Name:CRISWELL, JAMIE KATHERINE (LMFT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:KATHERINE
Last Name:CRISWELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1927
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2927
Mailing Address - Country:US
Mailing Address - Phone:919-285-4802
Mailing Address - Fax:919-882-8096
Practice Address - Street 1:206 RALEIGH ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2263
Practice Address - Country:US
Practice Address - Phone:919-285-4802
Practice Address - Fax:919-882-8096
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1451106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6105334Medicaid