Provider Demographics
NPI:1235866922
Name:MCINNIS, JAZMYN DESIRA
Entity Type:Individual
Prefix:
First Name:JAZMYN
Middle Name:DESIRA
Last Name:MCINNIS
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 1:1190 W ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-2818
Mailing Address - Country:US
Mailing Address - Phone:704-296-6200
Mailing Address - Fax:
Practice Address - Street 1:284 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1831
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 101YP2500X, 1041C0700X, 106H00000X
NCA19893103T00000X
NCA17893164W00000X, 2084P0800X, 363A00000X, 363LP0808X, 364SP0809X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult