Provider Demographics
NPI:1518991587
Name:VELOZ-JEFFERSON, JACKELIN JENNIFER (EDS)
Entity Type:Individual
Prefix:MRS
First Name:JACKELIN
Middle Name:JENNIFER
Last Name:VELOZ-JEFFERSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 W VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2816
Mailing Address - Country:US
Mailing Address - Phone:919-274-4476
Mailing Address - Fax:919-554-9232
Practice Address - Street 1:122 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2816
Practice Address - Country:US
Practice Address - Phone:919-274-4476
Practice Address - Fax:919-554-9232
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2501103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107214Medicaid