Provider Demographics
NPI:1073012647
Name:BUSH, JACQUELINE (LMFT, BC-TMH)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:LMFT, BC-TMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W 4TH ST STE 321
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-1545
Mailing Address - Country:US
Mailing Address - Phone:704-879-1179
Mailing Address - Fax:704-490-4274
Practice Address - Street 1:227 W 4TH ST STE 321
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-1545
Practice Address - Country:US
Practice Address - Phone:704-879-1179
Practice Address - Fax:704-490-4274
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC7054106H00000X
NC2118106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty