Provider Demographics
NPI:1306937750
Name:ECCLESTON, JON WAYNE II (LCSW)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:WAYNE
Last Name:ECCLESTON
Suffix:II
Gender:M
Credentials:LCSW
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Mailing Address - Street 1:124 UNIONVILLE INDIAN TRL RD W
Mailing Address - Street 2:SUITE A1
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-5591
Mailing Address - Country:US
Mailing Address - Phone:704-608-0445
Mailing Address - Fax:704-821-9337
Practice Address - Street 1:124 UNIONVILLE INDIAN TRL RD W
Practice Address - Street 2:SUITE A1
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5591
Practice Address - Country:US
Practice Address - Phone:704-608-0445
Practice Address - Fax:704-821-9337
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2011-09-21
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Provider Licenses
StateLicense IDTaxonomies
NCC0047341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC004734OtherNC CLINICAL SOCIAL WORK
NC600913Medicaid