Provider Demographics
NPI:1598014011
Name:SELKIN, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:SELKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8832 BLAKENEY PROFESSIONAL DR STE 105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8832 BLAKENEY PROFESSIONAL DR STE 105
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6717
Practice Address - Country:US
Practice Address - Phone:704-631-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4996103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical