Provider Demographics
NPI:1144741760
Name:JARVIS, CRYSTAL G
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:G
Last Name:JARVIS
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 1:238 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:STUMPY POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27978-9662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:934 W KITTY HAWK RD
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-4280
Practice Address - Country:US
Practice Address - Phone:252-261-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional