Provider Demographics
NPI:1518485457
Name:TRANQUIL HARBOR FAMILY THERAPY, JESSICA BOOTH, PLLC
Entity Type:Organization
Organization Name:TRANQUIL HARBOR FAMILY THERAPY, JESSICA BOOTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:GLASSON
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT, LCAS-A
Authorized Official - Phone:919-498-4556
Mailing Address - Street 1:1062 HICKORY HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-9193
Mailing Address - Country:US
Mailing Address - Phone:919-498-4556
Mailing Address - Fax:919-708-9089
Practice Address - Street 1:319 COURT SQ
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5658
Practice Address - Country:US
Practice Address - Phone:919-498-4556
Practice Address - Fax:919-708-9089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1843106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1942682786OtherPERSONAL NPI NUMBER