Provider Demographics
NPI:1285969097
Name:DAUGHERTY, JANNA ROUNTREE (LCSW, LCAS)
Entity type:Individual
Prefix:MRS
First Name:JANNA
Middle Name:ROUNTREE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LCSW, LCAS
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 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 HEART DR
Practice Address - Street 2:ECU PHYSICIANS FAMILY MEDICINE
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8944
Practice Address - Country:US
Practice Address - Phone:252-744-4611
Practice Address - Fax:252-744-3201
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1359101YA0400X
NCC0047221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007523Medicaid
NC137JMOtherBCBSNC
NC137JMOtherBCBSNC
NC2878517BMedicare PIN