Provider Demographics
NPI:1225385156
Name:BALLETTA, JESSICA JAZZ (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JAZZ
Last Name:BALLETTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 MERIDIAN MARKET DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-5760
Mailing Address - Country:US
Mailing Address - Phone:718-813-4649
Mailing Address - Fax:
Practice Address - Street 1:3937 WESTERN BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-1936
Practice Address - Country:US
Practice Address - Phone:919-821-0790
Practice Address - Fax:919-518-9476
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0129281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical