Provider Demographics
NPI:1467741918
Name:HARTMAN, JACQUELYN RENEE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:RENEE
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:RENEE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 DEER VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRING
Mailing Address - State:NC
Mailing Address - Zip Code:27592-8559
Mailing Address - Country:US
Mailing Address - Phone:919-867-4042
Mailing Address - Fax:
Practice Address - Street 1:111 WINDEL DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4475
Practice Address - Country:US
Practice Address - Phone:919-867-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8527101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104773Medicaid