Provider Demographics
NPI:1255314720
Name:COLEMAN, JENNIFER KING (PHD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KING
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 TATTERSALLS DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8021
Mailing Address - Country:US
Mailing Address - Phone:910-762-7888
Mailing Address - Fax:
Practice Address - Street 1:1717 SHIPYARD BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8019
Practice Address - Country:US
Practice Address - Phone:910-392-7877
Practice Address - Fax:910-392-7886
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2808103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000297Medicaid