Provider Demographics
NPI:1033990122
Name:MARINELLIE, JENNIFER FAY (LCAS-A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FAY
Last Name:MARINELLIE
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:FAY
Other - Last Name:DAUBENMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:205 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8712
Practice Address - Country:US
Practice Address - Phone:910-295-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-29419101YA0400X
NCP0199841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)