Provider Demographics
NPI:1174118673
Name:FOSTER, JESSICA (MHL)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MHL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 SAVANNAS RUN DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-1699
Mailing Address - Country:US
Mailing Address - Phone:336-987-4578
Mailing Address - Fax:
Practice Address - Street 1:4545 JESSUP GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9407
Practice Address - Country:US
Practice Address - Phone:336-542-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-1210320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities