Provider Demographics
NPI:1093904021
Name:COLEMAN, JACQUETTA RESHON
Entity Type:Individual
Prefix:MS
First Name:JACQUETTA
Middle Name:RESHON
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 OLD IRONSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4091
Mailing Address - Country:US
Mailing Address - Phone:704-599-1536
Mailing Address - Fax:
Practice Address - Street 1:3021 OLD IRONSIDE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-4091
Practice Address - Country:US
Practice Address - Phone:704-599-1536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC158853101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health