Provider Demographics
NPI:1316685761
Name:MANGUM, JESSICA GRACE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:GRACE
Last Name:MANGUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 CREEKSTONE CT
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-7111
Mailing Address - Country:US
Mailing Address - Phone:919-745-0464
Mailing Address - Fax:
Practice Address - Street 1:2172 N SALEM ST STE 105
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27523-6457
Practice Address - Country:US
Practice Address - Phone:919-639-4360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty