Provider Demographics
NPI:1336677095
Name:LARUE, JESSICA NADINE (LMFTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NADINE
Last Name:LARUE
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4409
Mailing Address - Country:US
Mailing Address - Phone:704-640-3487
Mailing Address - Fax:
Practice Address - Street 1:215 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-4409
Practice Address - Country:US
Practice Address - Phone:980-581-4305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12021A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist