Provider Demographics
NPI:1689904401
Name:REGISTER, JACK A II (MSW, LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:REGISTER
Suffix:II
Gender:M
Credentials:MSW, LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 W RADIANCE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1228
Mailing Address - Country:US
Mailing Address - Phone:336-588-9156
Mailing Address - Fax:
Practice Address - Street 1:416 W RADIANCE DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1228
Practice Address - Country:US
Practice Address - Phone:336-588-9156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1723101YA0400X
NCC0049681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)