Provider Demographics
NPI:1508059445
Name:JERNIGAN, ERICA OWEN (MA, LPC)
Entity Type:Individual
Prefix:MISS
First Name:ERICA
Middle Name:OWEN
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 S CLIFFDALE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3808
Mailing Address - Country:US
Mailing Address - Phone:336-659-7784
Mailing Address - Fax:336-679-2909
Practice Address - Street 1:305 N STATE ST
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-5245
Practice Address - Country:US
Practice Address - Phone:336-679-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4132101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool