Provider Demographics
NPI:1427488295
Name:FORTIER, JACLYN (MA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:FORTIER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:FORTIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1011 PEMBERTON HILL RD STE 202
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502
Mailing Address - Country:US
Mailing Address - Phone:919-410-3852
Mailing Address - Fax:
Practice Address - Street 1:1011 PEMBERTON HILL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502
Practice Address - Country:US
Practice Address - Phone:919-410-3852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14288101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health