Provider Demographics
NPI:1356828180
Name:CAMILO, JENNY M (CSAC-24946)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:M
Last Name:CAMILO
Suffix:
Gender:F
Credentials:CSAC-24946
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 SORRELL CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-8301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2231 E MILLBROOK RD STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1746
Practice Address - Country:US
Practice Address - Phone:919-307-8165
Practice Address - Fax:919-307-8167
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCSAC-24946101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)