Provider Demographics
NPI:1346680279
Name:BOSSEMEYER, JILLIAN NUNN (MS, CAS, LPA)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:NUNN
Last Name:BOSSEMEYER
Suffix:
Gender:F
Credentials:MS, CAS, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1149
Mailing Address - Country:US
Mailing Address - Phone:716-912-5575
Mailing Address - Fax:
Practice Address - Street 1:617 N SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-5558
Practice Address - Country:US
Practice Address - Phone:716-912-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4305103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool