Provider Demographics
NPI:1053466870
Name:PETTY, JACQUELYN (LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 WALTER BRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-0341
Mailing Address - Country:US
Mailing Address - Phone:919-770-4588
Mailing Address - Fax:
Practice Address - Street 1:130 CARBONTON RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4009
Practice Address - Country:US
Practice Address - Phone:919-774-6521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4807101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103319Medicaid