Provider Demographics
NPI:1417772211
Name:POWELL, JG MWAMBA (LCAS-A)
Entity type:Individual
Prefix:
First Name:JG
Middle Name:MWAMBA
Last Name:POWELL
Suffix:
Gender:
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 LAMAR ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-3310
Mailing Address - Country:US
Mailing Address - Phone:919-286-1509
Mailing Address - Fax:
Practice Address - Street 1:1913 LAMAR ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3310
Practice Address - Country:US
Practice Address - Phone:919-286-1509
Practice Address - Fax:910-897-2009
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29168101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)