Provider Demographics
NPI:1568772382
Name:PHELPS, JARYN ROYCE (AUD)
Entity Type:Individual
Prefix:
First Name:JARYN
Middle Name:ROYCE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JARYN
Other - Middle Name:ROYCE
Other - Last Name:PULICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-838-8493
Mailing Address - Fax:704-838-8494
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3256
Practice Address - Country:US
Practice Address - Phone:704-838-8493
Practice Address - Fax:704-838-8494
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9065231H00000X
NC654BD01237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
774097OtherWELLCARE
SCSAN088Medicaid
SC30110579OtherSELECT HEALTH OF SC
NC7413427Medicaid
9119790OtherAETNA
NC162CVOtherBCBSNC
NC4492644OtherCIGNA
NC4492644OtherCIGNA
SCSAN088Medicaid