Provider Demographics
NPI:1417655671
Name:AREVALO, JACQUELINE MICHELLE (LCMHC-A)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:AREVALO
Suffix:
Gender:F
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11460 W STEWART ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NC
Mailing Address - Zip Code:27557-9477
Mailing Address - Country:US
Mailing Address - Phone:815-529-9091
Mailing Address - Fax:
Practice Address - Street 1:8601 SIX FORKS RD STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5931
Practice Address - Country:US
Practice Address - Phone:919-294-8981
Practice Address - Fax:919-999-2497
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18354101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health