Provider Demographics
NPI:1730673864
Name:OTHIOSSINIR, JAMAAL (LCSW-A)
Entity Type:Individual
Prefix:
First Name:JAMAAL
Middle Name:
Last Name:OTHIOSSINIR
Suffix:
Gender:M
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 EDINBURGH DR
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-9058
Mailing Address - Country:US
Mailing Address - Phone:336-470-4791
Mailing Address - Fax:
Practice Address - Street 1:2732 ANN ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5111
Practice Address - Country:US
Practice Address - Phone:336-229-5905
Practice Address - Fax:336-513-4203
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0125081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical