Provider Demographics
NPI:1962171728
Name:FADEL, JENNIFER (LCMHCA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FADEL
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 ROSWELL AVE UNIT 504
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1685
Mailing Address - Country:US
Mailing Address - Phone:704-609-8205
Mailing Address - Fax:
Practice Address - Street 1:5203 SHARON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4721
Practice Address - Country:US
Practice Address - Phone:704-554-9900
Practice Address - Fax:704-554-9956
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16911101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty