Provider Demographics
NPI:1386227395
Name:MEJIA-HOLGUIN, JENNIFER (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MEJIA-HOLGUIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2047 AUDREY DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1921
Mailing Address - Country:US
Mailing Address - Phone:914-338-3908
Mailing Address - Fax:
Practice Address - Street 1:603 COX RD STE B
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3432
Practice Address - Country:US
Practice Address - Phone:914-338-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12306A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12306AOtherLMFTA
NC15135204OtherCAQH