Provider Demographics
NPI:1235416215
Name:TATE, JESSICA G (CRC, LCAS, LPC, MAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:G
Last Name:TATE
Suffix:
Gender:F
Credentials:CRC, LCAS, LPC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4238 DUDLEYS GRANT DR APT C
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-7942
Mailing Address - Country:US
Mailing Address - Phone:252-702-7503
Mailing Address - Fax:
Practice Address - Street 1:501 PALADIN DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7826
Practice Address - Country:US
Practice Address - Phone:252-353-5346
Practice Address - Fax:252-321-7300
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10900101YP2500X
KY168173101YP2500X
NC2062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10900OtherLPC
NC2062OtherLCAS