Provider Demographics
NPI:1679665590
Name:LOCKLEAR, JENNIFER B (NCC, LPCS, LCAS, CSI)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:LOCKLEAR
Suffix:
Gender:F
Credentials:NCC, LPCS, LCAS, CSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-9504
Mailing Address - Country:US
Mailing Address - Phone:336-757-0258
Mailing Address - Fax:336-945-0342
Practice Address - Street 1:6620 SHALLOWFORD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9504
Practice Address - Country:US
Practice Address - Phone:336-757-0258
Practice Address - Fax:336-945-0342
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5123101YP2500X, 101YA0400X, 101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103500Medicaid
NC1780013037OtherGROUP NPI