Provider Demographics
NPI:1487956397
Name:STATON, JESSIE RAY (LCAS, LCSW)
Entity type:Individual
Prefix:MR
First Name:JESSIE
Middle Name:RAY
Last Name:STATON
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Gender:M
Credentials:LCAS, LCSW
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Mailing Address - Street 1:4300-110 SAPPHIRE CT
Mailing Address - Street 2:PORT HUMAN SERVICES
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:252-830-7540
Mailing Address - Fax:252-752-0074
Practice Address - Street 1:144 COMMUNITY COLLEGE RD
Practice Address - Street 2:SUITE B
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-8047
Practice Address - Country:US
Practice Address - Phone:252-209-8932
Practice Address - Fax:252-332-2483
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2016-09-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC1727101YA0400X
NCC0079291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112245Medicaid