Provider Demographics
NPI:1427469295
Name:WRINKLE, LAURA JEANE (CSAC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEANE
Last Name:WRINKLE
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 BELL FORK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-6312
Mailing Address - Country:US
Mailing Address - Phone:910-347-2205
Mailing Address - Fax:910-347-2216
Practice Address - Street 1:719 PINEWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7707
Practice Address - Country:US
Practice Address - Phone:717-577-8504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2925101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)