Provider Demographics
NPI:1659145738
Name:ANNUNZIATA, JESSICA RAE (LCMHCA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:ANNUNZIATA
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RAE
Other - Last Name:ANNUNZIATA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCMHCA
Mailing Address - Street 1:10430 PARK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8541
Mailing Address - Country:US
Mailing Address - Phone:704-281-1754
Mailing Address - Fax:
Practice Address - Street 1:10430 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8540
Practice Address - Country:US
Practice Address - Phone:704-281-1754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19239101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health