Provider Demographics
NPI:1750676466
Name:MARDIS, JACQUELINE WOOD (LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:WOOD
Last Name:MARDIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6855 BRYANSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5313
Mailing Address - Country:US
Mailing Address - Phone:910-868-5266
Mailing Address - Fax:
Practice Address - Street 1:6855 BRYANSTONE WAY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-5313
Practice Address - Country:US
Practice Address - Phone:910-868-5266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2939101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional