Provider Demographics
NPI:1508438060
Name:MCINTYRE, JERICA MARIE (LPA)
Entity Type:Individual
Prefix:
First Name:JERICA
Middle Name:MARIE
Last Name:MCINTYRE
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9410 FETLOCK CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-1870
Mailing Address - Country:US
Mailing Address - Phone:828-712-9952
Mailing Address - Fax:
Practice Address - Street 1:4012 PARK RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2378
Practice Address - Country:US
Practice Address - Phone:704-332-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4594103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist