Provider Demographics
NPI:1124692736
Name:PAGE, JESSICA FARRON (LCMHCA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:FARRON
Last Name:PAGE
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 KINGS RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-6212
Mailing Address - Country:US
Mailing Address - Phone:704-466-3022
Mailing Address - Fax:844-272-6196
Practice Address - Street 1:2225 KINGS RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-6212
Practice Address - Country:US
Practice Address - Phone:704-466-3022
Practice Address - Fax:844-272-6196
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16478101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health