Provider Demographics
NPI:1124769302
Name:ELLIOTT, JASMINE (LCMHCA)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:ELLIOTT
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 1:483 BLACK ANGUS DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-6834
Mailing Address - Country:US
Mailing Address - Phone:252-202-9648
Mailing Address - Fax:
Practice Address - Street 1:1140 KILDAIRE FARM RD STE 206
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4597
Practice Address - Country:US
Practice Address - Phone:252-680-1029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17392101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health