Provider Demographics
NPI:1134639594
Name:COLEMAN, JALISA MARIE (NCC, LCMHC)
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:MARIE
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:NCC, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 KENILWORTH AVE # UNITE315
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-1508
Mailing Address - Country:US
Mailing Address - Phone:196-219-7719
Mailing Address - Fax:
Practice Address - Street 1:1511 KENILWORTH AVE # UNITE315
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-1508
Practice Address - Country:US
Practice Address - Phone:196-219-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13386101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health