Provider Demographics
NPI:1235689589
Name:JAMISON, KANETRA LACHELLE (LCSWA)
Entity Type:Individual
Prefix:MS
First Name:KANETRA
Middle Name:LACHELLE
Last Name:JAMISON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 ELISE MARIE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8120
Mailing Address - Country:US
Mailing Address - Phone:704-579-3024
Mailing Address - Fax:
Practice Address - Street 1:1231 ELISE MARIE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28214-8120
Practice Address - Country:US
Practice Address - Phone:704-579-3024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0097551041C0700X
SC11628104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker