Provider Demographics
NPI:1528206786
Name:LOCICERO, JACK P SR (LPC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:LOCICERO
Suffix:SR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5178 OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-2450
Mailing Address - Country:US
Mailing Address - Phone:336-624-6733
Mailing Address - Fax:
Practice Address - Street 1:5178 OXFORD DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-2450
Practice Address - Country:US
Practice Address - Phone:336-624-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional