Provider Demographics
NPI:1558449678
Name:TERRY, JENNIFER MUNGLE (MS, LPC, CRC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MUNGLE
Last Name:TERRY
Suffix:
Gender:F
Credentials:MS, LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 OLD DOCK TRL
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-6906
Mailing Address - Country:US
Mailing Address - Phone:919-389-0711
Mailing Address - Fax:866-401-2407
Practice Address - Street 1:515 KEISLER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7097
Practice Address - Country:US
Practice Address - Phone:919-389-0711
Practice Address - Fax:866-401-2407
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC264131Medicare UPIN
NCD3275Medicare UPIN
NC139MGMedicare UPIN
NC200182265Medicare UPIN