Provider Demographics
NPI:1134513369
Name:MAYNE, JESSIE (APRN)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:MAYNE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 WADE AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-1390
Mailing Address - Country:US
Mailing Address - Phone:919-443-2360
Mailing Address - Fax:
Practice Address - Street 1:220 N MAIN ST
Practice Address - Street 2:STE. 500
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2161
Practice Address - Country:US
Practice Address - Phone:919-443-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19355363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health